Diagnosis and Management of

Hemorrhage in Oral Surgery

DR MOHAMMAD AKHEEL
OMFS PG
 What is meant by Hemorrhage ?

Prolonged or uncontrolled bleeding is often

referred to as hemorrhage.

The amount of blood lost as a result of

hemorrhage can range from minimal to
significant quantities.
 Hemorrhage in Surgery

Hemorrhage can occur to a greater or lesser

degree during all surgical procedures and it’s
management depends upon whether the patient is
hematologically normal or suffers from some
disturbance in the normal clotting mechanism.
Hemorrhage in Oral Surgery
 Hemorrhage in Oral Surgery

The overwhelming majority of patients who

undergo oral surgical procedures are those who
have normal haemostatic mechanism.

Therefore, significant or major hemorrhages are

not that common in oral surgery except in patients
who have a bleeding / clotting disorder or those
who are on anticoagulants.
 Hemorrhage in Oral Surgery

However, uncontrolled and persistent bleeding

can occur in some healthy patients after dental
extraction.

Therefore, it is still important to achieve proper

hemostasis in all patients during oral surgical
procedures, so as to prevent excessive post-
operative blood loss.
 Normal Mechanism of Hemostasis

Hemostasis is a complicated process.

It involves a number of events

 Hemostasis - Normal Mechanism

1. VASCULAR PHASE

2. PLATELET PHASE

3. COAGULATION PHASE
 VASCULAR PHASE

When a blood vessel is damaged,

vasoconstriction results.
 PLATELET PHASE

Platelets adhere to the damaged surface

and
form a temporary plug.
 COAGULATION PHASE

Through two separate pathways, the

Intrinsic and Extrinsic, the conversion of
fibrinogen to fibrin is complete. Fibrin
tightly binds the platelets to form a clot
 THE CLOTTING MECHANISM

INTRINSIC EXTRINSIC
Collagen Tissue Thromboplastin
XII
XI VII
IX
VIII

V FIBRINOGEN
(I)

PROTHROMBIN THROMBIN
(II) (III) FIBRIN
 HEMOSTASIS
DEPENDENT UPON:

Vessel Wall Integrity

Adequate Numbers of Platelets

Proper Functioning Platelets

Adequate Levels of Clotting Factors

Proper Function of Fibrinolytic Pathway

 Hemorrhage in Oral Surgery

Hemorrhage following Oral Surgical procedures

can occur due to local or systemic causes.

In healthy patients the postoperative bleeding is

mainly due to local causes.
Local causes of hemorrhage in oral surgery

Local causes of hemorrhage originate in either

soft tissue or bone.
Local causes of hemorrhage in oral surgery –
Soft tissue bleeding

Soft tissue bleeding is either arterial, venous, or

capillary in nature.
Local causes - Soft tissue bleeding in oral surgery

Arterial bleeding is bright red and spurting in nature.

Arteries in the soft tissues at risk during oral surgical

procedures are the lies posterior portion of hard palate)
greater palatine artery and the buccal artery (lies lateral
to the retromolar pad)
Local causes - Soft tissue bleeding in oral surgery

Venous blood is dark red in color and flows

steadily and heavily especially if the vein is large .

Capillary bleeding is bright red in color and is

more of a minimal ooze.
Local causes – Osseous (Bony) bleeding in oral
surgery

Troublesome bone bleeding originates either from

nutrient canals in the alveolar region, central
vessels, such as the inferior alveolar artery, or
from central vascular lesions (Hemangioma or
Vascular malformation)
Systemic causes of hemorrhage in oral surgery

Some patients with heriditary conditions such as

hemophilia, Von Willebrand’s disease are susceptible for
hemorrhage following oral surgical procedures.

Patients with thrombocytopenia (decreased platelet

count) , Leukemia e.t.c., are also at risk of prolonged
bleeding after surgery.

Patients with uncontrolled hypertension.

Systemic causes of hemorrhage in oral surgery

Patients with H/O prosthetic heart valve replacement,

Stroke (Cerebrovascular accident) e.t.c., take oral
anticoagulants like Aspirin or Warfarin to prevent the
occurrence of a thromboembolic episode.

These patients are also at risk of prolonged severe

bleeding during and after an oral surgical procedure.
Types of Hemorrhage - Primary Hemorrhage

This occurs during the surgery, as a result of injury like

cutting or laceration of the artery or bleeding from
bone.

This also occurs when surgery is done in an infected

area with a lot of granulation tissue.

It can also occur after a very short period of time

immediately after surgery.

This type of bleeding is really normal and can be

controlled easily.
 Types of Hemorrhage - Intermediate /
Reactionary Hemorrhage

This type of bleeding occurs within a few hours after

surgery.

This type of bleeding occurs as a result of failure of

coagulation to occur (as in patients with systemic
bleeding problems or those on anticoagulants)

Patients who have unknowingly disturbed / dislodged the

clot are also prone for this type of bleeding.
Types of Hemorrhage - Secondary Hemorrhage

This occurs after 7 to 10 days after surgery. This is

mainly due to partial division of blood vessel in
combination with infection of the wound (Like patient’s
who undergo radical neck dissection e.t.c.,).

This type of bleeding is not very frequently encountered

after oral surgery procedures.
 Management of Primary Hemorrhage in Normal
patients

The management of bleeding during surgery (Primary

bleeding) can be achieved by the following means,

(i) Securing / ligation of blood vessels with silk sutures.

(ii) Use of pressure swab to achieve hemostasis.
(iii) Use of electrocautery to achieve hemostasis.
(iv) Use of hemostatic agents like bone wax, surgicel,e.t.c.,
(v) Hypotensive anaesthesia (G.A) and use of
vasoconstrictors in L.A.
 Local Measures ( Synthetic Materials)

There are several materials that are commercially

available that are used locally for achieving
adequate hemostasis.
Local Measures: Surgicel (Oxidised Regenerated
Cellulose)
Local measures: Gelfoam with activated thrombin
Local Measures: Avitene (Microfibrillar
Collagen)
 Local Measures:
Etik Collagen (Packed collagen)
Local Measures: Tranexamic acid 5%
Local Measures: Tranexamic acid 5% in Syringe
Local Measures: Irrigation of wound with
Tranexamic acid
Local Measures: Suturing the wound
Local Measures: Pressure with oral packs
 Management of Intermediate Hemorrhage in
Normal patients

The management of bleeding that occurs immediately

after surgery (Reactionary bleeding) involves proper
examination of the surgical wound to identify the site
of bleeding (i.e ) from bone or soft tissue.

(i) If bleeding is from bone then the hemostatic agents

like bone wax or gelfoam is usually used.

(ii) If bleeding is from soft tissues then, ligation /

cauterization of blood vessels along with the use of
hemostatic agents like surgicel and suturing of the
wound is carried out.
Management of Secondary Hemorrhage in Normal
patients

The management of this type of bleeding that occurs a

few days after surgery involves the removal of any debris
from the wound surface that promotes the infection of the
wound.

Identify the source of bleeding and treat as would be

done in a patient with secondary bleeding.

Surgical stents can be placed over extraction sockets for

stabilization of clot and prevention of wound
contamination.
 Management of Hemorrhage in patients with
bleeding disorders / and those on anticoagulant
therapy

The usual protocol involved in the treatment of this

group of patients consists of pre-operative blood
investigations and preoperative correction of the
underlying deficiency (Replacement of Clotting factors /
platelets) if any in these patients.

Subsequently, after this appropriate local measures are

used to decrease the chances of post-operative bleeding.
LABORATORY EVALUATION

PLATELET COUNT
BLEEDING TIME (BT)
PROTHROMBIN TIME (PT)
PARTIAL THROMBOPLASTIN TIME (PTT)
THROMBIN TIME (TT)
 PLATELET COUNT

NORMAL 100,000 - 400,000 CELLS/MM3

< 100,000 Thrombocytopenia

50,000 - 100,000 Mild Thrombocytopenia

< 50,000 Severe Thrombocytopenia

 BLEEDING TIME

PROVIDES ASSESSMENT OF PLATELET

COUNT AND FUNCTION

NORMAL VALUE
2-8 MINUTES
 PROTHROMBIN TIME

Measures Effectiveness of the Extrinsic Pathway

NORMAL VALUE
10-15 SECS
PARTIAL THROMBOPLASTIN TIME

Measures Effectiveness of the Intrinsic

Pathway

NORMAL VALUE
25-40 SECS
 THROMBIN TIME

Time for Thrombin To Convert

Fibrinogen Fibrin
A Measure of Fibrinolytic Pathway

NORMAL VALUE
9-13 SECS
Management of Hemorrhage in patients with
uncontrolled hypertension.

This group of patients need appropriate medical

consultation for initiation of medical treatment to
decrease their Blood Pressure.

Thus once their B.P is controlled, then the bleeding

decreases and with local measures the hemorrhage is
controlled.
THANK YOU