Control of Bleeding During Tooth Removal - Part 1
By Dr. Philip Banghart

lntraoperative (primary) control of bleeding when extracting teeth is predicated upon gaining control of all factors that may prolong bleeding.  Surgery should be as atraumatic as possible. Carefully placed incisions and gentle management of soft tissue is paramount in this endeavor.  Great care should be taken to avoid crushing soft tissue, because crushed tissue can lead to prolonged periods of oozing.  Sharp bony edges should be smoothed, trimmed or removed. All granulation tissue should be carefully removed from the socket, necks of adjacent teeth and on the internal aspect of soft tissue flaps.  The soft tissue, especially the periosteum, should be carefully inspected for the presence of specific bleeding vessels.  If identified, the bleeding should be controlled with direct pressure.  If this fails, clamping the bleeder with a hemostat followed by suture ligation is necessary.  An alternate means for soft tissue hemostasis is discrete use of cautery to coagulate the bleeding vessels.

Once the soft tissue has been thoroughly inspected for bleeding, the surgeon should evaluate the bone for bleeding.  If excessive bleeding is occurring from a bony foramen, or nutrient canal, a blunt instrument such as a hemostat can be used to burnish the bone around the foramen.  Often times, this will occlude the bleeding foramen.  If this fails, bone wax can be applied to occlude the foramen.  A third alternative is to use cautery to coagulate the bony foramen.

Once these measures have been accomplished, the bleeding socket is covered with a damp 2 x 2 or 4 x 4 inch sponge that is folded to fit directly over the surgical area.  The patient is instructed to bite down firmly on the gauze.  After 10-15 minutes the extraction site should be re-examined for hemostasis.  The surgeon should not dismiss the patient from the office until hemostasis is achieved.  Once adequate hemostasis is verified the patient is discharged with new damp gauze in position.  The patient is instructed to leave it in place an additional 30 minutes.

If bleeding persists after these measures and arterial bleeding has been ruled out, additional measures should be taken to achieve hemostasis.  Absorbable gelatin sponge (Gelfoam) is commonly used to achieve hemostasis in this situation. Typically, this material is compressed in the extraction site and secured with a figure-eight suture over the socket.  The absorbable sponge forms a scaffold for blood clot formation.  A gauze is then placed over the extraction site and held in place with firm pressure.

A second hemostatic material is oxidized, regenerated cellulose (e.g. Surgicel) which is superior to a gelatin sponge in promoting coagulation.  It is easier to condense in a socket using pressure; the gelatin sponge becomes friable when wet and is harder to pack.  Consequently, cellulose is reserved for more persistent bleeding.

Another material that can be utilized to control persistent bleeding from a socket is collagen.  Collagen accelerates coagulation by promoting platelet aggregation.  Collagen is currently available in several forms.  Most commonly, microfibrillar collagen (e.g. Avitene) is used.  It is loose and fluffy and can be packed into an extraction socket.  It can be bolstered with sutures followed by gauze packs.  Collagen is also manufactured in a highly condensed form in the shape of a plug (e.g. Collaplug) or as tape (e.g. Collatape).  In this form it is easily adapted and applied.

If the patient's coagulation ability is a concern, a gelatin sponge can be soaked in a liquid preparation of topical thrombin and pre-emptively inserted into the socket.  Thrombin bypasses all steps in the coagulation cascade and directly catalyzes the conversion fibrinogen to fibrin forming a clot.  A figure-eight suture is used to secure the sponge and a gauze pack is placed in the usual fashion.

Intraoperative Bleeding:
- Usual sources: granulation tissue vessels in periosteum or nutrient canals in bone.
- Bleeding from granulation tissue is treated by adequate debridement and curettage.
- Bleeding vessels: best identified under good lighting, adequate flap retraction and suctioning.
- Once identified, vessels are clamped with hemostat then ligated or cauterized.
- Hemostatic agents are used to control persistent bleeding.
- Hemostatic agents: absorbable gelatin sponge (Gelfoam), regenerated cellulose (Surgicel), collagen (Avitene, Collaplug, Collatape).

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