Although most patients do not suffer prolonged postoperative bleeding following extractions or other oral surgical procedures, there are times when a patient will contact the dentist with a complaint of prolonged bleeding following a routine procedure. Phone consultations are, at best, difficult to sort through and compromise the clinician’s ability to correctly diagnose the problem. Definitive diagnosis requires physical examination; however, professional judgment will dictate whether the patient needs to be seen immediately. When in doubt, an examination is wise.
Signs and Symptoms
Often the patient will experience tenderness to palpation near the surgical site, along with edema consistent with the procedure. Trismus and limited opening may also be a problem, as well as paresthesia secondary to edema and/or hematoma at the surgical site. A large mass of oozing blood clot may be found at the extraction site precluding complete interdigitation of the teeth, and in fact may cause an imprint of the opposing teeth and also be a cause of continued bleeding when this contact occurs. Occasionally, there is brisk, bright red bleeding as a result of platelet plug deficiency or previously unidentified vessels (bleeders) in the surgical area.
The diagnosis of persistent bleeding may be made after any exuberant clot formation has been removed and after reapplying pressure dressings for a period of 15 to 20 minutes. Then, if bleeding persists, further examination and treatment are necessary.
|Step 1||Reanesthetize the patient to allow careful examination and manipulation of the tissues in the surgical site. Anesthesia should be obtained with a local anesthetic without a vasoconstrictor . (Use of a vasoconstrictor may control the bleeding only to have it return if the source has not been identified when the effects of the vasoconstrictor have worn off.)|
|Step 2||Following application of local anesthetic, thoroughly irrigate, suction , and inspect the surgical site. If a single bleeding source can be identified, obtain control using electrocautery or hemostatic agents such as Surgicel or Gelfoam.|
|Step 3||After the placement of hemostatic dressings and suturing, observe the area 15 to 20 minutes to confirm hemostasis. If bleeding persists, the site should be packed and the patient referred to an oral and maxillofacial surgeon or emergency facility for blood testing.|
|Step 4||If the patient shows any signs of hypovolemia or hemorrhagic shock, vital signs should be obtained and the patient should be referred to an emergency treatment facility.|
Alveolar Osteitis (Dry Socket)
Alveolar osteitis, or dry socket, is a common occurrence following the surgical removal of mandibular molars—occurring in 20% to 25% of patients—but is rarely observed in the maxilla. The suspected mechanism involves lysis or loss of the blood clot following extraction of a tooth. The incidence appears to increase in smokers and in those taking oral contraceptives.
Signs and Symptoms
Although the patient may do well for the first few days after extraction, there is increasing pain and discomfort 3 to 4 days later, near the extraction site. The patient experiences radiating pain, a deep ache, and a foul taste and odor. Surrounding soft tissues appear normal but the alveolus is either empty or contains material that is easily displaced with irrigation.
Diagnosis of alveolar osteitis is based on presenting symptoms of continuing or increasing pain 3 to 4 days following extraction. Pain is usually unrelenting. Dry socket can occur even when the soft tissue flaps are closed, leaving no apparent opening between the socket and the oral cavity. The symptoms are sometimes more revealing than clinical examination of the socket, particularly in third molar sites.
|Step 1||Gently irrigate with warm saline solution (95-105°F). Increased pain may be seen with irrigation, which further supports the diagnosis of dry socket.|
|Step 2||Placement of obtundent dressing (iodoform gauze lightly soaked with benzocaine, eugenol, balsam of Peru, and chlorobutanol).|
|Step 3||Reevaluate the patient in 24-48 hours, remove dressing, irrigate with warm saline solution, and redress.|
|Step 4||Continue this cycle for up to 14 days.|
|Step 5||If there is no resolution within 14 days, consider other sources of pain and symptoms (eg, jaw or alveolar fracture, infection, injury to adjacent tooth, and nerve injury).|
Surgical procedures in the posterior maxilla can result in an oroantral communication. This complication can lead to fluids passing freely from the oral cavity into the maxillary sinus. Defects of less than 5 mm often will heal spontaneously with local measures, whereas large exposures require surgical intervention. Anatomical considerations that predispose patients to such complications include dilacerated roots, retained palatal root tips, a thick buccocortical plate, and maxillary sinus pneumatization.
Signs and Symptoms
Displacement of fluids into the nose via the sinus, retro-orbital pain, nasal stuffiness with bleeding following nose blowing, and air bubbles upon exhalation all suggest an oroantral communication. The clinical examination may allow direct visualization of the oroantral communication. Air bubbles may be seen at the extraction site when the patient exhales. Radiographic examination should include a Waters’ projection to reveal any of the following, which are indicative of sinusitis: air-fluid level, mucosal thickening, or opacification of the involved sinus.
Diagnosis is based on an opening from the oral cavity into the maxillary sinus. This is usually made by direct visualization. Air bubbles at the extraction site when the patient exhales are a good indication if the opening is not visually apparent.