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Oral & Dental Health

Post-Extraction Bleeding

Bleeding from the tooth socket following an extraction, occurring either immediately (primary) or after 24 hours (secondary).

Also known as: Bleeding After Tooth Removal

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Referral and warning signs

When to refer

Refer to Dentist/Oral Surgeon/Hospital (HC4/H/RR) if: Bleeding is profuse or uncontrolled by local measures (pressure packing, suturing). Suspected underlying bleeding disorder requiring investigation/systemic management. Need for advanced haemostatic agents or blood transfusion. Bleeding persists beyond 24 hours despite local measures.

Red flags

  • Profuse, uncontrollable bleeding.
  • Signs of shock (tachycardia, hypotension, pallor, altered mental status).
  • Known severe bleeding disorder.
  • Bleeding from multiple sites.

Signs and symptoms

  • Active bleeding or oozing from the extraction socket.
  • Blood clot may be present, absent, or dislodged.
  • Patient may report persistent bleeding or spitting blood.
  • Signs of significant blood loss (pallor, tachycardia, hypotension) if bleeding is severe/prolonged.

Risk factors

  • Patient factors: Disturbing the clot (rinsing, spitting, touching), Vigorous physical exercise soon after extraction, Underlying bleeding disorder (Haemophilia, vWD, thrombocytopenia), Anticoagulant/antiplatelet medication use (Warfarin, aspirin, clopidogrel), Liver disease.
  • Local factors: Traumatic extraction, Retained tooth or bone fragments (spicules) in socket, Sharp bony edges, Infection in the socket (secondary bleeding), Failure to follow post-op instructions.

Diagnosis

Clinical assessment

Direct observation of bleeding from socket. Clear any existing clot to visualize source (soft tissue vs bone). Assess patient's haemodynamic status (BP, pulse). Inquire about medical history (bleeding disorders, meds) and adherence to post-op instructions.

Investigations

  • Check BP, pulse.
  • Inspect socket after clearing clot.
  • Consider Hb/Hct if significant loss suspected.
  • Consider coagulation studies (INR, aPTT, Platelets) if underlying disorder suspected.

Diagnostic criteria

Clinical observation of bleeding from extraction socket beyond expected minor oozing.

Management

Non-pharmacological management

  • General Measures: (LOC: HC4)
  • - Reassure patient.
  • - Assess ABCs if bleeding severe.
  • - Check BP, pulse.
  • - Apply local anaesthesia if needed for examination/treatment.
  • - Gently clear away loose clots from socket with gauze/suction.
  • - Identify bleeding source (soft tissue, bone, vessel).
  • - Pressure Pack: Place a sterile gauze pack directly over the socket and instruct patient to bite firmly and continuously for 30 minutes.
  • - Suturing: If bleeding is from soft tissue margins, consider suturing the gingiva over the socket.
  • - Address Local Factors: Remove any obvious bone spicules, smooth sharp bony edges.
  • - Haemostatic Agents (if available): Pack socket with absorbable haemostatic material (e.g., Gelfoam, Surgicel).
  • - If bleeding stops, reinforce post-op instructions.
  • Secondary Bleeding: Assess for infection (clean socket, consider antibiotics).

Pharmacological treatment

  • Local anaesthetic with vasoconstrictor (e.g., Lidocaine with Adrenaline) infiltrated around socket can help control bleeding.
  • Tranexamic acid (soaked gauze applied to socket, or mouthwash/oral if systemic cause) - specialist use.
  • Management of underlying bleeding disorder (factor replacement, desmopressin) or adjustment of anticoagulants (in consultation with physician/haematologist).

Monitoring

Observe patient for at least 30 minutes after achieving haemostasis. Check vital signs. Assess need for further intervention or referral.

Complications

  • Significant blood loss / Anaemia.
  • Hypovolemic shock (rare, severe cases).
  • Infection of the socket.
  • Haematoma formation.
  • Delayed healing.

Prevention

  • Thorough pre-operative medical history (bleeding disorders, medications).
  • Atraumatic extraction technique.
  • Achieve good initial haemostasis before discharging patient.
  • Clear post-operative instructions (bite on gauze, avoid rinsing/spitting/hot liquids/smoking/straws for 24h, rest).

Patient education

  • Post-Extraction Instructions (Crucial):
  • - Bite firmly on gauze pack provided for 30-60 minutes.
  • - Replace gauze if soaked, continue biting.
  • - DO NOT rinse mouth, spit forcefully, smoke, drink through straw, or consume hot liquids for first 24 hours.
  • - Rest, avoid strenuous activity for 24 hours.
  • - Soft diet initially.
  • - Gentle warm salt water rinses can start AFTER 24 hours.
  • - Contact clinic/hospital if bleeding restarts and is uncontrolled by biting on gauze.

Uganda-specific notes

Pressure packing with gauze is the mainstay. Suturing sockets can help. Assess for systemic causes if bleeding is excessive/persistent. Referral needed for uncontrolled bleeding.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 23, Section 23.2.4.1

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