Extraction is considered one of the easiest and yet the trickiest of all dental procedures. Done properly and with proper preoperative investigations, an extraction wound heals without any untoward events. But sometimes due to some reasons the wound does not heal as it should and continues bleeding without provocation.
How does a clot form?
Whenever there is a cut or an open wound on any tissue there is associated loss of blood which is called bleeding. However, in normal situations, once bleeding starts the body marches its control systems in place to control the loss of blood. Blood when exposed to air forms collagen fibers. These fibers attract platelets which adhere to these fibers. The platelets in turn release a chemical to attract more platelets. A mesh is soon formed containing collagen fibers, RBCs, WBCs and platelets. These signal a host of clot formation processes to commence and soon a compact plug is formed over the bleeding vessel which corks the bleeding.
In an extraction wound there are certain basic difficulties to overcome in order to seal the bleeding. The wound is of the nature of a socket, often without any approximating soft tissues. When tissues approximate over a wound, the clot is maintained within the envelop of such tissues and is prevented from dislodging. No such luck in a tooth extraction socket.
Prolonged post extraction bleeding may be primary or secondary. Primary bleeding is that which doesn’t stop right after the extraction. It may either be frank bleeding or slow oozing. Secondary or reactionary bleeding is one which occurs several hours after the initial clot formation has taken place.
Primary bleeding occurs if there is any deterrent in the clot formation mechanism. Hemophilia and other bleeding disorders cause severe post-operative bleeding. Thrombocytopenia or low platelet count is one of the reasons for continued bleeding. Presence of granulation tissue in the socket, or traumatic extractions are other causes for protracted bleeding.
Secondary bleeding is often due to loss of blood clot due to patient’s ignorance of post-extraction instructions issued by the dentist.
The protracted bleeding in the second event is fairly easy to overcome. Administer a local anesthetic to the patient and curette the socket with a spoon excavator to induce fresh bleeding. Proceed with the normal post-extraction procedure of placing a pressure pack and reiterate the instructions to the patient. Severe bleeding can be controlled with oral tranexamic acid administration.
Bleeding in case of hemophilia or thrombocytopenia may be somewhat more difficult to control than secondary bleeding. For mild bleeding ethamsylate oral administration is enough to arrest the oozing. Where bleeding is not controlled by ethamsylate, an intramuscular injection of botropase or tranexamic acid is often enough to control the bleeding.
Other measures to control the bleeding are gelfoam or bone wax.
Proceed with the pressure pack. Ask the patient to chew hard on the pack and maintain the pressure for about an hour to an hour and a half. Following this the patient should remove the pressure pack and not place any new pack or cotton back in.
The best way to avoid this possibility is to ensure the bleeding time and clotting time of all patients before you do an extraction. The normal range of platelets are 2,00,000 to 450,000. Anything lesser than 150,000 should be investigated, and the extraction should be postponed to after the platelet count is restored.