There are just a few moments in a dental clinic that can really make your heart pound. Perhaps the most intense among them is when an extraction site simply refuses to stop bleeding. Your patient starts to get anxious, and you can’t help but feel the pressure too. Post-extraction bleeding can sometimes be a minor annoyance, or it could, in other instances, signal a much more serious underlying issue.
The key difference between a clinician who handles such situations calmly and one who gets flustered is knowledge. You absolutely need to understand where the bleeding is coming from, what its cause might be, and what tools you have at your disposal to effectively bring it under control.
In this article, we’re going to give you a complete, practical guide to managing all types of post-extraction bleeding—from the straightforward, simple cases right up to the more complex scenarios involving Bleeding Disorders.
The First Step: Accurate Diagnosis—Is the Bleeding Local or Systemic?
Before you do anything else, you must ask yourself the most crucial question: Is this blood originating directly from the wound itself, or is it indicative of a broader, systemic issue within the patient’s body?
1. Local Bleeding
This is the more common and generally simpler type. Here, the problem lies within the Extraction Site itself. The causes are often:
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Laceration: Perhaps your instrument inadvertently caused a gum tear during the extraction.
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Bone Fracture: This happens if a small piece of the jawbone comes out with the tooth.
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Injury to Blood Vessels: You might have inadvertently nicked a small artery or vein.
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Nutrient Canals: Sometimes, tiny blood vessels within the bone continue to bleed.
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The Patient’s Actions: The patient might not be following instructions—rinsing too vigorously or disturbing the clot.
2. Systemic Bleeding
Now, this is where the problem becomes more significant and potentially more dangerous. The cause isn’t localized to the wound; instead, it’s a Systemic Disease the patient has that impairs their blood’s ability to clot properly. Examples include:
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Liver Disease: This is critical because the liver is responsible for producing clotting factors.
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Blood Thinners: Medications like Aspirin and Warfarin.
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Hereditary Bleeding Disorders: Conditions such as Hemophilia.
Managing Local Bleeding: Pressure is Paramount!
If you’ve confirmed the issue is local, the solution is usually quite simple and direct.
The Golden Rule: Pressure is Key. Grab a piece of sterile Gauze, form it into a small ball, place it directly over the bleeding site, and instruct the patient to bite down firmly and continuously for 5 minutes. In roughly 90% of cases, this alone is entirely sufficient.
If direct pressure isn’t quite cutting it, we then start bringing out our arsenal of additional “weapons”:
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Gauze with Hydrogen Peroxide (H2O2): Hydrogen Peroxide helps promote Platelet Aggregation and also causes Vasoconstriction in smaller blood vessels.
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Gelatin Sponge or Gelfoam: This is truly one of dentistry’s most valuable inventions. It’s a gelatin-based sponge that absorbs blood and naturally dissolves over time.
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How it works: It effectively creates a “scaffold” where blood cells can accumulate, forming an Artificial Blood Clot.
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An Added Benefit: It significantly reduces the risk of Dry Socket, which is why we particularly love using it for diabetic patients and after extracting impacted wisdom teeth.
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Commercial Examples: You’ll find it as Surgi Foam or Gelaspon.
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Suturing: If the wound is larger or the gingiva is lacerated, there’s no better solution than closing the wound with a couple of sutures. Suturing brings the wound edges together and applies direct pressure to the vessels.
Understanding the Blood’s Language: The Clotting Pathways Story
To effectively manage systemic bleeding, you need a quick grasp of how blood clots. Think of it like two distinct roads that both lead to the same destination: a “clot.”
1. Extrinsic Pathway
This is the pathway that’s initiated when there’s tissue damage from outside the blood vessels.
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We measure it using a test called: Prothrombin Time (PT), or more commonly, the International Normalized Ratio (INR).
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Normal INR value is 1. The higher this number, the greater the blood’s fluidity (thinner blood).
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As a general rule: We can usually perform routine dental procedures if the patient’s INR is less than 3.5, or at most 4, provided all necessary precautions are taken (1).
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The most famous medication affecting this pathway: Warfarin.
2. Intrinsic Pathway
This pathway kicks in when there’s damage to the blood itself inside the vessels.
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We measure it using a test called: Partial Thromboplastin Time (PTT).
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The most famous medication affecting this pathway: Heparin.
Blood Thinners: You Absolutely Must Know Them!
Your patients taking blood thinners generally fall into two main categories:
Type One: Antiplatelet Drugs
These medications work by preventing platelets from sticking together.
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The most common ones are: Aspirin and Plavix (Clopidogrel).
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How to manage them: Typically, we don’t need to stop these medications before routine extractions. However, you absolutely must be prepared with local hemostatic agents like Gelfoam and be ready to suture (2).
Type Two: Anticoagulant Drugs
These medications act directly on the clotting factors themselves.
Heparin:
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This is typically the “emergency” one. It’s often given in hospital settings, for example, to dialysis patients.
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Its effect is immediate but only lasts for about 4-6 hours.
Warfarin (e.g., Marevan):
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This is the most common anticoagulant taken at home. Patients with a history of blood clots or heart valve issues often take it.
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Its effect starts one to three days after administration and lingers in the body for 3-6 days.
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The most dangerous aspect: It has numerous Drug Interactions, especially with antibiotics like Flagyl (Metronidazole) and NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) such as Ibuprofen.
The Management Protocol for Patients on Anticoagulants
So, a patient comes in who’s taking blood thinners, or you suspect it from their medical history. What do you do?
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Diagnosis First: Never proceed without knowing their current numbers. Request a recent PT/INR test, ideally performed no more than 24-48 hours prior.
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Consult with Their Treating Physician: You must speak with their cardiologist or primary care doctor. They are the only ones who can decide if the medication can be stopped or if the dosage needs to be reduced. Never make this decision on your own.
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Anesthetize with Caution: Avoid nerve blocks whenever possible, especially the IANB (Inferior Alveolar Nerve Block), as it carries a higher risk of causing a hematoma (internal bleeding). Rely on infiltration anesthesia if feasible.
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Atraumatic Extraction: The gentler you are during the extraction, the less bleeding you’ll encounter.
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Local Hemostatic Agents: These are mandatory. You absolutely must use Gelfoam inside the socket and place good, tight sutures.
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Suture Loosely: Don’t completely seal the wound. Leave a slight gap for any minor blood to egress, preventing the formation of a hematoma.
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Safe Pain Relievers: Absolutely avoid prescribing NSAIDs like Ibuprofen. The safe pain reliever here is Paracetamol (Acetaminophen).
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Safe Antibiotics (with Warfarin): Most antibiotics interact with Warfarin. The safest options are Amoxicillin and Clindamycin (3).
Signs That Should Make You Suspect an Undiagnosed Bleeding Problem!
Keep an eye out for these indicators, even if the patient isn’t aware they have a bleeding disorder:
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Small red spots on the palate or cheek (Petechiae).
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Blue bruises (Ecchymosis) anywhere in their mouth.
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Spontaneous Gingival Bleeding (bleeding from the gums without injury).
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A long history of significant bleeding after any previous extractions.
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Nosebleeds (Epistaxis) that take an unusually long time to stop.
If you observe any of these signs, you absolutely must request coagulation tests before even considering an extraction.
A Final, Extremely Important Warning: Patients with Hemophilia absolutely do not belong in your private practice. They must be managed in a fully equipped hospital setting, under the direct supervision of a complete medical team.
