Persistent bleeding following a dental extraction is an uncommon, but well-reported post-operative complication of dental surgery. It can be caused by a variety of factors which are divided into local and systemic causes.
Local causes
- Irritation of the blood clot
This commonly occurs when the blood clot in the socket is not allowed to stabilise. Among the main causes are vigorous rinsing, disturbing socket with tongue or failure to apply pressure on socket with gauze
- Hyperaemic tissues
What this means is that the area surrounding the extracted tooth is very inflamed and swollen with small blood vessels. Therefore, following the extraction of the tooth there is a higher likelihood for bleeding to be more persistent.
- Consumption of hot food or beverages
Besides the possibility of clot disturbance, the high temperature would likely increase blood flow and henceforth precipitate bleeding
- Difficult or prolonged extraction
In a prolonged extraction procedure, tissue damage would usually be more severe. This would result in more inflammation. There is also a higher possibility of fracture of the bony socket. All this would contribute to a greater incidence of persistent bleeding.
Systemic causes
- High blood pressure
Patients with blood pressure readings of 160/100 mmHg or higher are more likely to bleed. This could be caused either by an undiagnosed condition, anxiety due to the procedure or the patient simply forgetting to take their regular medication. Extraction should ideally be postponed and the patient referred to their medical practitioner to correct the blood pressure.
- Consumption of medication affecting clotting
More and more individuals are taking medications such as aspirin or warfarin for various medical conditions. These medications disturb the formation of a stable clot and may be a cause of post extraction bleeding if the dentist is unaware of it. Most would not require much modification of their medication intake, however precautions should be taken for more difficult cases.
- Bleeding disorders
Individuals with conditions such as Haemophilia A or B (lack of certain clotting factors), thrombocytopaenia (low platelet count) would be expected to bleed post extraction should the condition not be identified. A referral to a physician or haematologist would be done to ensure the required clotting factors and platelets are restored before extraction is performed.
Patients may or may not be aware that their medical condition or medication places them at some risk, therefore it is important these matters are identified when patients complete the medical history questionnaire prior to treatment.
Commonly post-extraction bleeding occurs because the patient did not follow post-extraction instructions in biting the gauze properly and frequent rinsing and spitting.
The usual presentation is of a large blood clot that forms over the tooth socket without actually stopping the bleeding. This leads to a red, jelly-like mass, which gradually increases in size as the socket continues to ooze blood underneath it. For as long as the large clot remains in place the socket will not stop bleeding.
Management of Bleeding after Tooth Extraction
- Manual pressure on a gauze pack placed over the area will be used by the dentist to arrest the bleeding. The gauze size should be small to just cover the extraction socket. The gauze which is used may be moistened so that the blood doesn’t coagulate in the gauze and blood clot is not dislodged when the gauze is removed.
- A small amount of blood is mixed with the saliva. So the patient should not be too alarmed about the amount of blood loss he or she is having.
- After the tooth extraction procedure, the patient is advised to firmly bite (not chew) on the gauze for at least 30 minutes. The gauze should be held in the mouth for 30-45 minutes. The patient should try to minimise talking for a minimum of 2-3 hours after the tooth extraction.
- After surgical wisdom tooth removal, slight oozing may occur up to 2-3 days.There may be blood-tinged saliva.
What to avoid so that bleeding is not precipitated
- You should not smoke for at least 48 hours after the extraction which can interfere with the healing. Smoking can further create negative pressure which can dislodge the clot and can further lead to dry socket.
- You are also advised to not to suck or spit too much which creates negative pressure and may cause mechanical irritation to the tooth extraction site. You should not drink water with a straw after the tooth extraction.
- You are advised to rest and not perform strenuous exercises up to 24 hours following the extraction which may elevate the blood pressure and subsequently stimulate the bleeding.
Steps to be taken if bleeding persists
- Firstly, you should avoid vigorous rinsing of the mouth as it can dislodge the clot formed at the extraction site.
- You can then place a piece of gauze (provided by the dentist) at the tooth extraction site again and keep it there for a minimum of 30 minutes for bleeding to stop. You should gently bite on the gauze pack with constant pressure.
- Alternatively, you can also bite on a tea bag for 30 minutes. The tea bag should be moistened with water and is then folded in half. Tannic acid which is present in the tea will reduce the bleeding by constricting the blood vessels.
- Failing that you can also moisten a clean cotton handkerchief. (Do not use tissue paper or cotton wool at this stage) .Wrap this into a wad so that it is narrow enough to fit between teeth on either side of the socket, but wide enough to cover the whole socket. It should be sufficiently bulky so that when the teeth are closed together, the wad exerts a lot of pressure on the socket.
- If bleeding persists after 30 minutes of constant pressure contact the dental practice for advice.
What happens when the dentist sees me?
- The dentist (if not the same one who did the extraction) would usually take a thorough history of the events leading up to and following the extraction
- A few questions will be asked about any medical conditions that were missed earlier for eg. missed medications, blood disorders, high blood pressure etc
- If a medical condition is confirmed, an urgent referral will be made to the relevant medical practitioner for further management.
- If there is no relevant medical condition, the dentist may proceed to do the following:
- Clean and wash the tooth socket to determine location and presence of bleeding and the remove the jelly-like blood clot mentioned earlier
- Removal of any foreign body that may have lodged in the socket, thereby disturbing clot formation.
- Placement of a haemostatic dressing into the socket and instructing you to bite down on a gauze placed over the socket. This dressing acts as a scaffold for platelets and clotting factors to adhere to.
- Some stitches may also be placed if needed.
- The dentist may prescribe tranexamic acid which acts to stablise the clot
Bleeding several days after Tooth Extraction
Bleeding which occurs several days after tooth extraction is known as secondary bleeding. It is due to infection of the wound which causes loss of clot and erosion of vessels in the granulation tissue. Before stitching or packing the socket in case of secondary bleeding, the extraction socket wound is examined carefully for any foreign body. Antibiotics may be given to the patient.
References
- http://shwethadental.com/index.php/articles/239-bleeding-after-tooth-extraction
- http://www.dental.cam.ac.uk/downloads/dis-post-extraction-bleeding.pdf
- http://www.ouh.nhs.uk/patient-guide/leaflets/files%5C110812dentalextractions.pdf
- http://www.drbonine.com/stop_bleeding.html
| Last Reviewed | : | 6 November 2014 |
| Writer | : | Dr. Jeremy Lee Ju Kuan |
| Accreditor | : | Dr. Kok Tuck Choon |
