Hemostasis in

Oral Surgery
a,b, a,c
Amandip Kamoh, DDS *, Jason Swantek, DDS

KEYWORDS
 Hemostasis  Hemostic agents  Hemorrhage control

Bleeding during oral surgical procedures can be bothersome to the operator and time-
consuming to control. It may also compromise visibility and possibly the procedure
itself. This article will cover the area of hemorrhage control in surgery. The topic can
be divided into three main areas:

1. Preoperative assessment and identification of risk factors of bleeding

2. Intraoperative control of bleeding
3. Management of postoperative bleeding.

PREOPERATIVE ASSESSMENT

There are many confounding factors that can ultimately potentiate perioperative
bleeding as well as create difficulty in controlling bleeding. Therefore, it is essential
to obtain a comprehensive medical history that also entails all medications in the
patient’s regimen. A thorough medical history is the best screening technique to iden-
tify potential bleeding issues.
When managing the anticoagulated patient, one must consider preoperative, intra-
operative, and postoperative measures.
Preoperatively, if the patient is on anticoagulant therapy, one may need to break up
exodontia into multiple visits to decrease the amount of bleeding encountered.1
Timing of the appointment has to be taken into consideration with patients who are
at high risk for bleeding postoperatively; early morning appointments allow for patients
to return to the clinic, if bleeding persists despite all measures. In medically compro-
mised patients, laboratory values such as international normalized ratio (INR),
prothrombin time (PT), and platelet count may be of critical value.

The authors have nothing to disclose.

a
Oral and Maxillofacial Surgery, Woodhull Medical & Mental Health Center, Brooklyn, NY, USA
b
Oral & Maxillofacial Surgery, 65 Spring Meadow Drive #5, Williamsville, NY 14221, USA
c
Oral and Maxillofacial Surgery, 254 Brookdale Lane North, Palatine, IL 60067, USA
* Corresponding author. Oral and Maxillofacial Surgery, 65 Spring Meadow Drive #5,
Williamsville, NY 14221.
E-mail address: akamohdds@gmail.com

Dent Clin N Am 56 (2012) 17–23

doi:10.1016/j.cden.2011.06.004 dental.theclinics.com
0011-8532/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.
18 Kamoh & Swantek

Many patients’ daily regimen consists of anticoagulant therapy such as aspirin, clo-
pidogrel, warfarin, and heparin for underlying comorbidities. Therefore the clinician
should be well versed in hemorrhage control after oral surgery. Although some prac-
titioners advocate the discontinuation of anticoagulants before an oral surgical proce-
dure, it is usually unnecessary. For the majority of these cases, local hemostatic
measures are effective in managing postoperative bleeding. Stopping the anticoagu-
lant can have deleterious effects and likely poses a greater risk to the patient. It has
been assumed that stopping warfarin for short periods of time presents a negligible
risk to the patient. However, it has been reported that discontinuing anticoagulation
medication before a dental procedure gives a 1% incidence of serious thromboem-
bolic complication.2 Local hemostatic measures generally suffice when managing
patients on daily low doses of anticoagulants. More likely than not, the risk of discon-
tinuing anticoagulants is higher than the risk of perioperative bleeding.
All antiplatelet medications affect clotting by inhibiting platelet aggregation, but they
do so by a variety of different mechanisms. Aspirin irreversibly acetylates cyclo-
oxygenase, inhibiting the production of thromboxane A2, which results in decreased
platelet aggregation. Clopidogrel selectively inhibits adenosine diphosphate (ADP)-
induced platelet aggregation. Aspirin begins irreversibly inhibiting platelet aggregation
within 1 hour of ingestion, and clopidogrel begins within 2 hours; this lasts for the life of
the platelets (7–10 days). The formation of new platelets helps overcome this inhibitory
effect; complete recovery of platelet aggregation may occur in 50% of cases by day 3
and in 80% of cases by day 4. Aspirin and clopidogrel work synergistically to inhibit
platelet aggregation. Aspirin can double the baseline bleeding time, but this may still
be within the normal range. Clopidogrel is considered a more potent antiplatelet agent
and can prolong the bleeding time by 1.5 to 3 times normal. Combined use of aspirin
and clopidogrel produces additive and possible synergistic effects as the two block
complementary pathways in the platelet aggregation cascade. It is generally accepted
that the cardioprotective benefits of low-dose aspirin outweigh the potential for unto-
ward bleeding episodes in at-risk patients with cardiovascular disease. Nonsteroidal
anti-inflammatory drugs (NSAIDs) other than aspirin have a reversible effect on platelet
aggregation, and platelet function is restored once the drug is cleared from the circu-
lation. Minor surgical procedures can be safely performed without altering the antipla-
telet medication dose.3 When more than 2 or 3 teeth need to be extracted, it is
generally advisable to do this in multiple visits rather than have the patient stop the
anticoagulants.
Bleeding disorders can be broken up into disorders of intrinsic and extrinsic coag-
ulation pathways. The intrinsic pathway involves factors VIII, IX, XI, XII, which all affect
the activated partial thromboplastin time (aPTT). The extrinsic pathway involves factor
VII, which will affect the PT. The intrinsic and extrinsic pathways both lead up to the
common pathway, where factor X is activated to factor Xa. If there are any anomalies
along factors in either the intrinsic or extrinsic paths, the formation of the fibrin clot can
be compromised. Laboratory tests such as PTT and PT can help lead toward deter-
mining which pathway is affected, while bleeding time values will provide information
concerning platelet functionality.
There are many congenital disorders that may have an impact on hemostasis-such
as hemophilia, von Willebrand Disease, and others. Hemophilia is a rare bleeding
disorder that can range from mild to severe, depending on how much clotting factor
is present in the blood. Hemophilia is classified as type A or type B, based on which
type of clotting factor is lacking,factor VIII in type A and factor IX in type B. Von Wille-
brand disease is a inherited condition that results when the blood lacks von Willebrand
factor, a protein that helps the blood to clot and also carries another clotting protein,
 Hemostasis in Oral Surgery 19

factor VIII. There are also many acquired bleeding disorders can be caused by certain
factor deficiencies secondary to liver disease or vitamin K deficiency. These patients
are typically closely monitored by their primary care physicians or hematologists;
therefore more information can be obtained by contacting the appropriate provider.
Spolarichs’ study showed that many surgical patients fail to inform their surgeons of
their use of herbal medications in preoperative interviews; therefore it is even more
important to question patients specifically about herbal supplement usage.4 Herbal
supplements such as ephedra, ginger, garlic, gingko biloba, ginseng, dong quai, St
John’s wort, licorice, and kava kava can all have possible perioperative complications
such as prolonged bleeding. Pribitkin and Boger5 documented garlic’s inhibitory effect
on platelet aggregation in people, which occurs within 5 days of oral administration.
Ginger is a potent inhibitor of thromboxane synthetase and can theoretically prolong
bleeding times with long-term use. Ginkgo has been noted to have a potent inhibitory
effect on platelet activating factor and consequently on platelet aggregation. Dong
quai has been known to prolong PT and aPTT, and it may interact with the effects
of warfarin. Licorice inhibits platelet aggregation and contains coumarin. Kava has
been shown in vitro to cause platelet dysfunction through inhibition of thromboxane
synthesis. It is recommended that herbal supplements be discontinued 2 weeks
before patients undergo invasive surgical procedures.
Preoperatively, the surgeon should assess the bleeding risk of the patient as well as
the bleeding risk of the surgery. For example, extracting multiple teeth in a single visit
greatly increases the risk of perioperative bleeding.6 Patients with severe periodontal
disease or gingival inflammation are also placed at a higher risk of perioperative
bleeding. This surgical plan might involve scaling and root planing and chlorhexidine
gluconate mouth rinse 2 weeks before an elective procedure. Once the bleeding risk
is assessed, the surgeon can then formulate an intraoperative and postoperative plan.

INTRAOPERATIVE CONTROL OF BLEEDING

Management of bleeding has many key components that start with good surgical
technique as well as anesthetic support. The less bleeding the surgeon encounters,
the better visibility he or she will have. Typically, the control of bleeding starts before
the incision is made with the injection of a vasoconstrictor. Intraoperatively, the
surgeon may use various topical hemostatic agents to assist in the control of bleeding.

VASOCONSTRICTOR

The control of bleeding should start prior to incision with the infiltration of vasocon-
strictor into the surgical site. Epinephrine is the most commonly used vasoconstrictor,
which is usually combined with a local anesthetic.7 In a patient with significant cardio-
vascular disease, 0.04 mg (2 carpules of epinephrine 1:100,000) is the maximum
dosage. In the healthy patient, the maximum dosage of epinephrine is 0.2 mg (11 car-
pules of epinephrine 1:100,000).8 After the injection of epinephrine, a decrease in
gingival blood flow should be apparent in approximately 5 minutes.9

INTRAOPERATIVE CONSIDERATIONS

Intraoperatively, the surgeon must take into consideration planning of the incision as
well as surgical anatomy in the prevention of bleeding. The incision should be designed
so that the site will be closed over bony support. This allows the application of pressure
directly to the surgical site in the event of uncontrolled bleeding. The incision should
also be large enough to allow adequate access to the surgical site. A small flap has
20 Kamoh & Swantek

a great risk of inadvertent tearing, which is a large risk factor for bleeding. The mucosa
and periosteum should be sharply incised and elevated in an atraumatic manner. The
surgeon should also avoid vascular structures such as the mental vessels, greater pala-
tine artery, inferior alveolar artery and vein, and the lingual artery and vein.
If perioperative bleeding occurs, the mainstay of hemostasis is the application of
pressure to the surgical site. If the bleeding arises from an extraction site, pressure
can be applied to the site by packing the socket and having the patient bite forcefully
on a piece of gauze dressing. Pressure should be maintained for at least 3 to 5 minutes
to allow the formation of a blood clot. The gauze should be removed slowly so as to not
dislodge the clot. Another form of mechanical surgical hemostasis is suturing. Suturing
cannot only be used to obtain primary closure of the surgical site, but also to apply
continuous pressure to the site, allowing hemostasis to occur. A nonresorbable, multi-
filament suture is recommended in these situations, since it has a high tensile strength.
A figure-of-eight suture over an extraction site is common in combination with other
hemostatic agents to provide pressure within the walls of the extraction socket. Place-
ment of multiple interrupted sutures is also recommended. Although a running suture
is quicker to place than multiple interrupted sutures, if the running suture fails, then the
site is at risk for bleeding over the whole area that the suture was covering.
Electrocautery and chemical cautery are also options in achieving hemostasis.
These techniques work best if a site of brisk bleeding can be visualized and isolated.
Although cauterization is a great option, one must be cognizant of avoiding damage to
surrounding vital structures.

HEMOSTATIC AGENTS

Several topical hemostatic agents are currently available for use in oral and maxillofa-
cial surgery. The ideal hemostatic agent should be effective, safe to use within the
body, and affordable. They can be divided into two categories: active and passive
hemostatic agents. Passive hemostatic agents provide a framework where platelets
can aggregate so that a stable clot can form. Active hemostatic agents have biologic
activity and directly participate in the coagulation cascade to induce a clot.
Gelfoam (Pfizer, New York, NY, USA) is a porous, pliable, absorbable gelatin sponge
that is prepared from purified pork skin gelatin. This product has properties that allow
it to absorb about 40 times its weight in blood, and it can expand to 200% of its initial
volume. When applied to a site, Gelfoam provides a mechanical matrix, which facili-
tates clotting. The spongy physical properties of the gelatin sponge hasten clot forma-
tion and provide structural support to the forming clot. Gelfoam has very little tissue
reaction and liquefies in the oral cavity within a week, fully absorbing within 4 to 6
weeks. Although it is not necessary, thrombin can be applied to the Gelfoam before
use to aid in hemostasis.
Surgicel (Ethicon, Somerville, NJ, USA) is oxidized regenerated cellulose, derived
from plant-based alpha-cellulose. Surgicel has acidic properties due to a low pH,
and it achieves hemostasis via denaturation of blood proteins, mechanical activation
of the clotting cascade, and local vasoconstriction. This product is thought to be rela-
tively bacteriostatic when compared with other hemostatic agents, due to a low pH.
The acidic environment Surgicel creates can be harmful to any adjacent vital struc-
tures like the inferior alveolar nerve. Loescher and Robinson10 reported that Surgicel
can cause temporary sensory disturbances. Absorption of Surgicel will occur in
approximately 4 to 8 weeks.
Tranexamic acid is an antifibrinolytic agent that completely inhibits the activation of
plasminogen to plasmin, preventing the degradation of fibrin. In oral surgery,
 Hemostasis in Oral Surgery 21

tranexamic acid solution is most commonly given as a mouthwash postoperatively to

prevent bleeding. Ramstrom and colleagues11 demonstrated a significant reduction in
postoperative bleeding in the anticoagulated patient when a 4.8% solution of tranexa-
mic acid mouthwash was used postoperatively, 10 mL 4 times daily, for 7 days.
Studies have not shown any significant decrease in hemorrhage control when tranexa-
mic acid is used intraoperatively (irrigation, soaked gauze). An intraoperative tranexa-
mic acid injection can also be used as a hemostatic measure. Choi and colleagues12
showed that total blood loss during maxillary surgery was significantly reduced when
a bolus of tranexamic acid was given preoperatively. Aminocaproic acid solution,
although less potent than tranexamic acid, is an antifibrinolytic agent that is more
widely available in the United States and can be used as an alternative.
Chitosan-based products are a new generation of hemostatic medical products that
have been shown to achieve early hemostasis as well as improve postoperative heal-
ing. Chitosan is a naturally occurring, biocompatible, electropositively charged poly-
saccharide that is derived from shrimp shell chitin. This charge attracts the
negatively charged red blood cells forming an extremely viscous clot, which seals
the wound and causes hemostasis. The formation of a clot occurs independently of
the intrinsic or extrinsic clotting pathways and is effective for patients on anticoagulant
medications. Although these products are derived from shellfish, no reactions have
been found in skin testing using chitosan on shellfish-sensitive patients. HemCon
Medical Technologies, Incorporated (Portland, OR, USA) currently manufactures
many chitosan-based products including dental dressings. A recent study showed
that hemostasis was achieved in less than 1 minute in patients where HemCon dental
dressing was used, which was significantly faster than the control average hemostasis
time, 9.5 minutes. Approximately 32% of HemCon dental dressing-treated sites had
significantly better healing compared with the control sites.13

MANAGEMENT OF POSTOPERATIVE BLEEDING

Patient education, especially patients at a high risk of postoperative bleeding, is

essential in the immediate postoperative period. The patient must be made aware
that bleeding or minor oozing may persist for up to 24 hours after an extraction. If
the patient is on anticoagulant medication, this may prolong the bleeding. The impor-
tance of pressure dressing postoperatively is also invaluable and needs to be stressed
to the patient. All postoperative instructions should include the following: avoid rinsing
the mouth vigorously or spitting for 24 hours; avoid disturbing the socket with foreign
objects, and most importantly apply pressure over the socket firmly for 20 minutes. If
bleeding starts at any time postoperatively, the patient can be instructed to reapply
pressure over the surgical site for 20 minutes with either a gauze dressing or
a damp tea bag.
Management of the postoperatively bleeding patient can provide a challenge to the
practitioner. Postoperative hemorrhage in the anticoagulated patient is most likely to
occur within 6 days.14 The use of the surgical techniques and agents described previ-
ously as well as good anesthetic support will be invaluable. The application of pres-
sure to the surgical site can slow or halt the bleeding while an assessment of the
patient is made. First, it is prudent to assess the amount of blood loss the patient
has had since the surgery. Although hemorrhagic shock resulting from an intraoral
surgical site is rare, it cannot be forgotten. If the patient displays any signs of shock
(tachycardia, hypotension, cold/clammy skin, lethargy), then a rapid response should
be initiated with immediate intravenous fluid replacement to replenish the intravas-
cular volume and reestablish tissue perfusion.
22 Kamoh & Swantek

Drug interactions are often overlooked in a postoperative bleeding incidence. A

thorough review of the patient’s medications is necessary, especially if the patient
has started a new medication (antibiotic, pain medicine) since the surgery. For
example, warfarin has increased effects and a greater potential for bleeding when
combined with macrolides (erythromycin, azithromycin), sulfa-containing drugs,
NSAIDs, and quinolones. Immediate discontinuation of the interacting drug must be
considered in the treatment plan for hemostasis.
The intraoperative control of bleeding techniques described previously can be used
in the postoperatively bleeding patient. Often when the postoperative bleeding patient
presents, the surgical site is not only bleeding but often contains a large amount of
granulation tissue. The best means of hemorrhage control is to thoroughly irrigate
the surgical site and remove all visible granulation tissue under local anesthesia before
suturing. Although one may be inclined to use vasoconstrictor in these situations, this
should be avoided. Administering a vasoconstrictor (ie, epinephrine) will help cease
bleeding in the surgical site; however, the problem at hand is only being masked.
Once the epinephrine is eliminated from the surgical field about 2 hours later, bleeding
will most likely resume.

SUMMARY

Management of a bleeding surgical site can be very disconcerting to the inexperi-

enced practitioner. Preoperatively assessing a patient’s risk of perioperative bleeding
will allow the surgeon to be more prepared when an incident occurs. The use of good
surgical technique, proper anesthetic support, mechanical hemostasis techniques,
and topical hemostatic agents will allow the practitioner to work more efficiently.

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