Practice 10-Minute Consultation BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j1217
(Published 03 April 2017) Cite this as: BMJ 2017;357:j1217 What you need to know
A fit and well 25 year old man attends his local emergency department concerned about a bleeding tooth socket after having had a lower wisdom tooth extracted earlier that morning. Postoperative bleeding is a recognised complication after tooth extraction, with an incidence of up to 1.4% of patients undergoing lower wisdom tooth surgery.1 It can be difficult to achieve complete haemostasis within the oral cavity because of the highly vascular nature of the tissues and exposure of the open socket to the patient’s exploring tongue and fingers.2 In healthy patients, a low level ooze for 12-24 hours after extraction is normal as an organised clot forms in the tooth socket.23 The patient will have mildly bloodstained saliva that will decrease over time. Any active bleeding beyond this point often indicates a haemostatic problem and requires investigations and treatment.4 What you should coverSignificant, active haemorrhage must be addressed before taking a comprehensive history. It is essential to establish the degree of active bleeding and consider any predisposing factors as well as assessing how vulnerable the patient is to haemodynamic changes, such as extremes of age.
Table 1 Type of postoperative bleeding after tooth extraction by time13 Box 1: Systemic factors that increase the risk of bleeding after tooth extraction13
Box 2: Medications which increase the risk of bleeding after tooth extraction24
What you should doExaminationComplete a primary survey and ensure that the patient is haemodynamically stable. Reassure him and explain what you are going to do. Assess blood loss—To examine the socket, sit the patient upright under good illumination, and use suction or gauze to remove blood, saliva, and any “liver clots” (large, mobile clots resembling fresh liver, often associated with secondary haemorrhage and infection) if present. Syringing the socket with saline and use of forceps can assist this process. Is blood continually filling the mouth, or is just a sluggish ooze (fig 2⇓) evident? Is the bleeding associated with swelling and even airway compromise? Soft tissues—Is a high flow arterial bleed visible, or is there a tear in the gum or mucosa? Are signs of infection evident such as suppuration (pus), cellulitis and trismus, or secondary haemorrhage with liver clots?1 Bony structures—Is bone around the socket mobile on palpation, indicating fracture? When the patient bites, do all the teeth meet? Is it very painful? Jaw fracture can occur after a lower wisdom tooth extraction, but it is rare with an incidence of 0.0049%.6 If fracture is suspected, refer the patient for an urgent orthopantomogram and posterioranterior view radiograph of the mandible.7 ManagementBe aware that patients with excessive or prolonged bleeding may vomit as swallowed blood can irritate the stomach.7 If you suspect a haemostatic defect from the patient’s history, order appropriate laboratory screening tests such as a clotting screen, international normalised ratio (INR), and full blood count and liaise with haematology.2 Most patients will have simple slight oozing after tooth extraction, and box 3 describes how to manage these patients. Box 4 indicates when the patient should be referred. Box 3: Management of a patient with blood oozing from a tooth socket after extraction who is haemodynamically stable
Box 4: When should a patient be referred?
Education into practice
Patient involvementNo patients were involved in the creation of this article Footnotes
References
View Abstract Log inLog in using your username and passwordLog in through your institutionSubscribe from £164 *Subscribe and get access to all BMJ articles, and much more. Subscribe * For online subscription Access this article for 1 day for: You can download a PDF version for your personal record. How much blood is okay after tooth extraction?After tooth extraction, it is normal for the area to bleed and then clot, generally within a few minutes. It is abnormal if bleeding continues without clot formation, or lasts beyond 8 to 12 hours; this is known as post‐extraction bleeding (PEB).
Can I go to sleep if my tooth extraction is still bleeding?Sleeping on the back is necessary for ensuring any materials used to control the bleeding in the extraction site will not shift out of place. Keeping the head to the side while sleeping could cause the protective materials to shift a small bit, making it harder for the teeth to stay healthy.
Can you swallow too much blood after wisdom teeth removal?A certain amount of bleeding is to be expected following surgery. Slight bleeding, oozing, or redness in the saliva is not uncommon for 24 hours or more. Saliva can be swallowed, even if slightly blood tinged. You should not have a significant amount of blood in your mouth.
Can gauze pull out blood clot?Gauze placed against the wound will draw blood from the clot and this, likewise, is not a sign of bleeding. Place an old towel over your pillow for the first night to reduce risk of staining. If the bleeding persists, contact the office.
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