Bleeding

Etiology and Prevalence

Postoperative bleeding is a side-effect of dentoalveolar procedures. In healthy patients, postoperative bleeding is typically minimal and self-limited by the clotting processes. It is important to distinguish active bleeding from surgical site oozing. Patients will often complain of excessive bleeding because they have noticed blood in their saliva. Oozing should resolve within 36–72 hours postoperatively, should respond to pressure, and is generally a nuisance for the patient. In contrast, patients with an active bleed will often complain of their mouth filling with blood immediately after removing a gauze dressing or other local pressure measure.

Risk Factors and Prevention

Among the most important steps in the management of excessive postoperative bleeding is recognition of the at-risk patient. During the preoperative assessment, a detailed history should be obtained, including a history of disorders associated with coagulation, e.g. hemophilia, von Willebrand disease, use of medications such as antiplatelet agents like aspirin and clopidogrel (Plavix), vitamin K antagonists like warfarin (Coumadin), or heparin or its derivatives, e.g. enoxaparin (Lovenox) or fondaparinux (Arixtra), an individual or family history of bleeding with surgical procedures, excessive bleeding upon loss of deciduous teeth, and, in females, a history of menorrhagia.

As the average age of oral surgical patients increases due to prolonged life, practitioners will encounter a greater number of anticoagulated patients. Appropriate adjuvant therapy, such as discontinuation of anticoagulant medications, factor infusions, or use of clot-stabilizing medications, should be considered in patients with risk factors for bleeding or known bleeding diatheses. Of note, patients taking clopidogrel, aspirin and other non-steroidal anti-inflammatory medication do not need to stop their medications prior to routine dentoalveolar procedures.

Patients on warfarin pose a common and special problem for the dentist. The underlying medical problem, e.g. long-standing atrial fibrillation, deep vein thrombosis, prosthetic heart valve, or myocardial infarction, often prohibits discontinuing the anticoagulant. An acceptable, but uncommon, management strategy is to hospitalize the patient, discontinue the warfarin, and maintain the patient on a heparin bridge until the INR (international normalized ratio) returns to the normal range. An alternative option is to discontinue the warfarin 3 days preoperatively.

Care should be taken in considering the type of dentoalveolar surgery being performed. Many minor oral surgical procedures (such as single tooth extraction) can be done while the patient is anticoagulated, based on the coagulation profile. In general, for patients on warfarin, an INR <2.5 is generally acceptable if extraction of multiple (more than four) teeth is required. For extraction of one to three teeth, with no posterior teeth or surgical extractions, an INR of <3.0 is acceptable. Keeping this in mind for the patient who may need multiple extractions, staged visits may be most appropriate so discontinuation of the anticoagulants can be avoided.

Newer anticoagulants such as the oral factor Xa inhibitors (rivaroxaban and apixaban) and the oral thrombin inhibitor (dabigatran etexilate) have more rapid onset than warfarin, have fixed dosing, are not affected by food, have fewer interactions, and do not require monitoring. Despite the cost differential, they are therefore rapidly becoming the anticoagulants of choice for patients requiring anticoagulation and generally do not require any adjustment for routine dental extractions.

Treatment

Excessive postoperative bleeding can be prevented intraoperatively by appropriate tissue management and local measures. In general, careful removal of granulated/infected tissue, minimal manipulation of surgical flaps to avoid tearing, use of local anesthetic with vasoconstrictor, primary wound closure, and the application of topical agents, such as absorbable gelatin sponge, oxidized regenerated cellulose fabric, or chitosan bandage, can limit most postoperative bleeding. Direct pressure with gauze in the immediate postoperative setting is an important method of limiting bleeding as the initial clot forms. Patients should be instructed to continue to apply pressure to the wound until bleeding has stopped.

Bleeding that persists after the initial phase of clot formation should be treated first with local measures, starting with direct pressure to the surgical site. Careful examination of the operative site with illumination and magnification and good suction can be invaluable to identify the source of bleeding. It is not uncommon to identify an incompletely formed clot, a “liver clot”, that is mobile and continues to aggravate the site. Careful removal of the clot is critical to control the bleeding successfully. Use of local vasoconstricting agents, such as local anesthetics with a vasoconstrictor such as epinephrine, is appropriate once the source of bleeding has been identified. If the vasoconstrictor is applied to the area prior to identification of the bleeding vessel, identification will be complicated. The wound may need to be repacked with a local hemostatic agent and sutured. Arterial bleeds that cannot be controlled with local measures should be treated with ligation or electrocautery. If bleeding persists, embolization, proximal vessel ligation, or other endovascular procedures may be required.

Pain

Etiology and Prevalence

As with bleeding, postoperative pain is a side-effect of operative intervention. Pain associated with routine dentoalveolar procedures usually begins with the resolution of local anesthesia (6–12 hours) and typically peaks between 24 and 48 hours postoperatively.

Risk Factors and Prevention

Prevention of pain via intraoperative measures and adequate postoperative pain control measures is essential. Intraoperatively, minimizing tissue trauma and careful tissue manipulation will decrease inflammation and thus decrease pain. There is evidence that the administration of preoperative non-steroidal anti-inflammatory medications (salicylates, cyclooxygenase (COX)-2 inhibitors) can reduce the severity of postoperative pain. Postoperatively, the use of non-steroidal medications, as well as narcotic preparations with acetaminophen (APAP) (hydrocodone, oxycodone, tramadol) are useful for treatment of moderate to severe postoperative pain. In addition, the use of long-acting local anesthetics, e.g. 0.5% bupivacaine with 1 : 200 000 epinephrine, can be beneficial in delaying the onset of pain, which may allow the patient to start postoperative analgesics prior to the onset of pain.

Swelling

Etiology and Prevalence

Edema following the surgical removal of teeth and other routine dentoalveolar procedures is an expected finding during the postoperative course. The onset of swelling is typically between 12 and 24 hours following the procedure, with a peak swelling noted 48–72 hours postoperatively. Swelling typically begins to subside at 4 days postoperatively, with most patients experiencing resolution of surgical edema within 1 week postoperatively.

Prevention and Treatment

It is important to inform patients of this time course and that swelling is an anticipated postoperative finding. In the early postoperative period, the use of ice may help with the management of swelling. In addition, patients should be told to sleep with the head of their bed elevated and not to sleep on their side, so as to avoid dependent swelling. Finally, perioperative steroids may be used to prevent swelling in patients undergoing significantly invasive procedures (e.g. third molar extraction). While the use of perioperative steroids may produce moderate decreases in swelling, these medications are typically short in action.

Surgical site Infection

Etiology and Prevalence

Because the oral cavity is home to a wide variety of bacterial flora, any intraoral wound will be exposed to a broad spectrum of aerobic, anaerobic, and facultative organisms with pathogenic potential. As such, postoperative infections should be primary among concerns for the practitioner when performing oral surgical procedures. Though the routine use of antibiotics for prevention of postoperative infections is still debated, there are several measures that can be implemented to reduce the likelihood of postoperative wound infection.

Prevention

Prevention of postoperative infection begins with identification of the patient at risk. A number of studies have demonstrated that the incidence of postoperative inflammatory complications increases with age, smoking, pre-existing infection/pathology in the surgical area, oral contraceptive use, and lack of surgical experience. Wh/>