How do I manage postoperative bleeding following periodontal surgery?

(Peer-reviewed content that will appear in the JCDA OASIS “point of care” searchable database at www.jcdaoasis.ca – which will be introduced at the beginning of 2013)

How do I manage postoperative bleeding following periodontal surgery?

Brennan Mui, Thomas T. Nguyen, Simon D. Tran

Postoperative bleeding may present immediately, within the first 24 hours following periodontal surgery, or as delayed postoperative bleeding up to 7-10 days following surgery. Excessive bleeding may occur following routine periodontal surgical procedures, such as pocket reduction surgery or grafting, if stable hemostasis cannot be initially achieved. Normally, hemostasis is achieved within 30 to 60 minutes after surgical procedures through clot formation and maturation.

Presentation

Population

• More likely to occur in people taking medications (e.g., elderly patients) or herbal and dietary supplements

Risk Factors

• Certain systemic diseases and medications
• Factors related to the surgery or healing process may cause excessive and/or uncontrolled postoperative bleeding
• Coagulopathy
• Past history of prolonged bleeding

Signs and Symptoms

• Continuous flow, oozing, or expectoration of blood or copious pink saliva
• Hematomas may indicate a subjacent bleeding that has not been identifi ed during the procedure
• Bleeding may be accompanied by pain

Investigation

1. Identify the source and cause of the bleeding.
2. Ask the patient about the onset, severity, and duration of the bleeding, as well as their compliance with postoperative instructions to verify if local factors may have triggered the bleeding (e.g., trauma from brushing, chewing food, vigorous rinsing, spitting, smoking, or drinking through a straw).
3. Ask the patient if they were involved in intensive physical activity or if they consumed alcohol, as it may trigger bleeding.
4. Review the patient’s regular medication and whether ASA or other blood thinning drugs (e.g., Plavix®, Coumadin®, Pradax®) may play a role in the bleeding.
5. Perform an intraoral examination.
6. Note the location, presentation and severity of the bleeding.
7. Determine the anatomic structure(s) involved in order to determine the appropriate treatment approach.

Diagnosis

1. Questioning the patient and performing a clinical examination are sufficient to establish the diagnosis, cause, and contributing factors to postoperative bleeding. An attempt to determine the anatomic structure(s) involved will help orient the dentist towards a proper treatment approach.
2. The possibility of systemic coagulopathy should also be considered if the bleeding proves particularly diffi cult to control or if the cause cannot be determined. Laboratory tests such as complete blood count, bleeding time, coagulation time, tourniquet test, international normalized ratio (INR), prothrombin time (PT), and partial thromboplastin time (PTT) may be used to reliably help diagnose such cases.

Treatment

Common Initial Treatments

• If consulted by phone and there is mere oozing of blood: reassure the patient that the situation is normal for the first 12 to 24 hours. Instruct the patient to apply continuous pressure to the area with a moist gauze or tea bag for 30 minutes, then to reassess the bleeding and repeat if necessary.
• If bleeding is profuseor if the initial pressure treatment is insufficient:
  • Examine the patient clinically as soon as possible.
  • Determine the source of bleeding with the help of irrigation and suction.
  • Remove “liver clots”—blood clots that resemble fresh liver. Then re-apply pressure.
• If the source cannot be determined:
  • Apply firm pressure with gauze for 15 minutes.
  • Local anesthesia with vasoconstrictor may be applied to help control the bleeding, determine the source, and facilitate further investigation.
  • Block techniques should be prioritized over local infi ltration.
  • Beware of recurrent hemorrhage after the local effect of the vasoconstrictor dissipates.
  • If the bleeding is from residual granulation tissue (e.g., within an extraction socket or after fl ap surgery):
  • Consider its removal by curettage.
  • Bony bleeding can be treated with a bone fi le, hemostat, or rongeur forceps by crushing and burnishing the overlying bone.
  • Soft tissue bleeding may be treated by clamping with a hemostat to encourage coagulation.
  • If the bleeding persists after removal of the hemostat, vessel ligation with sutures, laser coagulation, or electrocautery may be necessary.
• Additional hemostatic agents such as absorbable gelatin (Gelfoam®), oxidized cellulose (Surgicel®), chitosan (HemCon™), or microfi brillar collagen (Avitene™) can be packed at the bleeding site.
• Sutures may be used to hold the hemostatic agent in place in addition to ligating the vessels in the area.
• Topical thrombin (THROMBIN-JMI®) and tranexamic acid (Cyklokapron® mouthwash, 5% aqueous solution) can also be considered for local application.
• Once hemostasis has been achieved, monitor the patient for at least 30 minutes before releasing them.
• A postoperative appointment should be scheduled one week later to assess tissue healing.

Alternate Treatments

If the bleeding persists after all methods have been attempted and the source remains unidentified: consider referring the patient to the ER and consulting a hematologist to evaluate a potentially undiagnosed coagulopathy.

Advice

Always describe postoperative instructions verbally immediately after periodontal surgery, and provide detailed written postoperative instructions with emergency contact information to reach the dentist directly.

Suggested Resources:

1. Falace DA. Emergency dental care: diagnosis and management of urgent dental problems. Philadelphia: Williams & Wilkins; 1995.
2. Hupp JR, Ellis E, Tucker MR. Contemporary oral and maxillofacial surgery. 5th ed. Mosby; 2008.
3. Newman MG, Takei H, Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology. 11th ed. Saunders; 2011.

JCDA-OASIS supports clinical decisions. However, it does not provide medical advice, diagnosis or treatment details. JCDA-OASIS is a rapidly accessible, initial clinical resource—not a complete reference.