Post-extraction Haemorrhage

Post-extraction haemorrhage is bleeding from a dental socket that continues or restarts after the extraction. It is classified as primary (at the time), reactionary (within the first 24 hours, as the effect of the local vasoconstrictor ends) and secondary (5 to 10 days after, usually from infection and clot breakdown).

Most bleeds are local and from gingival soft tissue or the socket, while some reflect a systemic disorder or drug effect. It is the commonest reason for emergency attendance after dental extraction.

Pathophysiology. Normal haemostasis requires vasoconstriction, platelet plug formation and a fibrin clot. Local trauma, infection and vascular tissue, or a systemic defect (anticoagulant or antiplatelet drug, thrombocytopenia, haemophilia, von Willebrand disease, liver disease, renal disease), interrupt this.

Secondary bleeding comes from loss of the clot because of infection, trauma or vigorous rinsing.

Persistent oozing or bleeding from the socket or gingiva, a clot that is dislodged, a metallic taste, bloody saliva, and swallowed blood leading to nausea. Heavy bleeding can lead to pallor, dizziness and tachycardia.

Ask about the timing and amount of bleeding, extraction complexity, anticoagulants (warfarin, direct oral anticoagulants), antiplatelets, herbal medicines, alcohol use, liver disease, family history of bleeding and previous bleeding after surgery.

Haemodynamic instability, uncontrolled bleeding despite local measures, large blood loss, a known bleeding disorder or INR over 4.0 need urgent admission.

• Assess haemodynamic state and the bleeding site: clean the mouth with suction and gauze, find the source (socket, gingival margin, soft tissue tear, arterial bleeder).
• Bloods when bleeding is persistent or a systemic cause is suspected: full blood count, prothrombin time or INR, activated partial thromboplastin time, fibrinogen, liver function, and group and save.
• INR on the day for warfarin users, and drug specific levels or timing of last dose for direct oral anticoagulants.
• Von Willebrand and factor assays with haematology input when a bleeding disorder is suspected.
• Radiograph for retained root, bone fragments or infection if secondary bleeding.

Differential diagnosis.

• Local socket bleeding from soft tissue or bone
• Bleeding due to anticoagulants or antiplatelets
• Thrombocytopenia and platelet dysfunction
• Inherited bleeding disorders (haemophilia, von Willebrand disease)
• Liver failure and vitamin K deficiency
• Infection with secondary haemorrhage
• Arteriovenous malformation and vascular tumour

• Local measures first: remove loose clot and apply firm pressure with damp gauze or a tea bag for 20 to 30 minutes, with the patient biting on it. Give local anaesthetic with a vasoconstrictor (lidocaine 2% with adrenaline 1 in 80 000) to the area, with caution in cardiovascular disease (maximum adrenaline 0.04 mg).
• Place a haemostatic agent in the socket (oxidised cellulose or gelatin sponge, or a collagen plug) and suture with resorbable 3/0 interrupted or figure-of-eight sutures over the socket. Use diathermy or bone wax for a bleeding vessel or bone.
• Tranexamic acid 5% mouthwash, 10 mL held for 2 minutes and spat out, four times daily for 2 days (up to 5 to 7 days in high risk patients), is useful in anticoagulated patients and those with bleeding disorders. Do not swallow.
• Warfarin: continue treatment when the INR is under 4.0 within 72 hours of extraction. Use local measures, and manage an INR over 4.0 with the prescriber. Do not stop warfarin without advice.
• Direct oral anticoagulants: delay the dose until haemostasis is secure, and plan the timing of future extractions with the prescriber. Reversal is for life threatening bleeding only: idarucizumab 5 g intravenously for dabigatran, and andexanet alfa or prothrombin complex concentrate for factor Xa inhibitors, under haematology advice.
• Antiplatelets: continue, and manage with local measures.
• Bleeding disorders: coordinate with haematology. Desmopressin 0.3 microgram/kg subcutaneously or by slow intravenous infusion for mild haemophilia A and type 1 von Willebrand disease (with fluid restriction and sodium monitoring, avoided in under 2 years of age and in cardiovascular disease), factor concentrates for other cases, and tranexamic acid.
• Systemic tranexamic acid when needed: 1 g orally three times daily (15 to 25 mg/kg) for 2 to 5 days, or 10 mg/kg intravenously by slow injection over 10 minutes. Reduce the dose in renal impairment (creatinine 120 to 250 micromol/L, 15 mg/kg twice daily; 250 to 500 micromol/L, 15 mg/kg once daily). Avoid with active thromboembolism or a history of convulsions.
• Thrombocytopenia: transfuse to keep platelets over 50 x 10^9/L for extractions or major oral surgery, when bleeding is active.
• Secondary haemorrhage from infection: debride the socket, give amoxicillin 500 mg orally three times daily for 5 days, or clindamycin 300 mg four times daily in penicillin allergy, and place haemostatic agents.
• Resuscitation for shock: intravenous access, fluids, blood products as needed.

Monitoring. Observe for 30 to 60 minutes after control, then review at 24 hours. Advise on avoiding hot drinks, rinsing, spitting, smoking and exercise for 24 hours. Check haemoglobin when blood loss was significant.

Referral and escalation. Refer to oral and maxillofacial surgery or the emergency department for persistent bleeding. Refer to haematology for bleeding disorders and anticoagulant management. Emergency escalation for haemodynamic instability, airway compromise or suspected major vessel injury.