Occasionally, patients will return to the dentist with bleeding after adequate intraoperative (primary) hemostasis has been achieved.  The reason for the post-operative (secondary) bleeding is often secondary to trauma precipitated by the patient continuing to spit blood from the mouth instead of effectively applying pressure with a gauze sponge.  Often times, a patient will continue to repeatedly change the gauze after surgery, which in effect disrupts the clot formation each time the gauze is removed from the extraction site.  Paradoxically, repeated replacement of gauze can perpetuate bleeding because the clot ends up "on the gauze" after each subsequent removal. Simply inform the patient that oozing of blood and blood-tinged saliva is normal for up to 12 - 24 hours after extraction and to avoid frequent unnecessary removal and changing of the gauze.

Nevertheless, the dentist must have a planned systematic protocol to control persistent post-surgical bleeding.  The patient should be positioned in the dental chair, and all blood and saliva evacuated with suction. Good lighting is imperative to determine the precise source of bleeding.  If generalized oozing is encountered, the bleeding site can be covered with a folded, damp 2 x 2 or 4 x 4 inch gauze held in place with firm pressure for 5 minutes.  This measure will control most bleeding.

If this measure is unsuccessful, local anesthesia should be administered so that the socket can be treated more aggressively.  Block techniques are recommended instead of infiltration.  Infiltrations with epinephrine solutions may result in artificial or temporary control of bleeding.  Recurrent bleeding may occur after the epinephrine dissipates.

Once local anesthesia has been achieved, the dentist should gently curette and debride the extraction site and suction out the old blood clot.  The initial goal is to determine whether the bleeding is coming from soft tissue or bone.  After careful flap retraction, the periosteum should be inspected to ascertain if the excessive bleeding is secondary to diffuse oozing or specific arterial bleeding.  Bone should be inspected for nutrient canal bleeding versus diffuse bleeding.  The same measures as discussed in Part I, Control of Bleeding During Tooth Removal, should be applied to manage the hemorrhaging.  These measures include removal of granulation tissue and smoothing sharp bony edges.  Soft tissue bleeders should be controlled with vessel clamping followed by ligation or vessel cauterization if direct pressure fails. If nutrient canals in bone are the source of bleeding, burnishing the surrounding bone, applying bone wax or cautery will typically control the hemorhaging.  Once the persistent bleeding is controlled a hemostatic agent is typically positioned in the extraction socket.  An absorbable gelatin sponge (Gelfoam) soaked in thrombin is usually quite effective.  A collagen plug (Collaplug) or oxidized cellulose (Surgicel) can also be utilized.

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