EM@3AM: Dental Bleeding

Author: Shane O’Donnell, DO (EM Resident Physician: UTSW – Dallas, TX); Zachary Aust, MD (Assistant Professor of EM/Attending Physician: UTSW – Dallas, TX) // Reviewed by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Welcome to EM@3AM, an emDOCs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

What is the diagnosis and your approach for bleeding control?

Answer: Dental Bleeding

Dental Anatomy

• Teeth can be named or numbered
• For documentation, it is useful to quickly reference the numbering system below

Tooth Extraction:

• Indications²
  • Severe tooth decay
  • Fractured / impacted / crowded tooth
  • Severe gum disease
• Often done with a combination of anxiolysis, local anesthetic, and a nerve block
• After extraction, there may be a gelatinous material left in place to assist in eventually implanting a replacement tooth.
• Post-extraction bleeding (PEB) is defined as bleeding continuing beyond 8-12 hours after extraction³
  • Incidence varies between 0-26%

History:

• Any use of antiplatelet or anticoagulation medications and when they last took them
  • Recent INR level if on Warfarin
• Personal or family history or bleeding disorders
  • Hemophilia patients: Ask about inhibitors, need for prophylactic factor replacement, and whether they brought their own factor replacement
• What type of dental procedure they underwent
• Interventions that have already been attempted to stop bleeding

Exam:

• Monitor for vital sign changes that would suggest worsening hypovolemic shock
• Remove gauze and ensure airway is patent
• Identify extraction site and evaluate for any expanding hematomas or early upper airway obstruction
• Mucosal bleeding is often a slow ooze; anything more should raise concern for underlying vascular involvement
  • While rare, an AVM in the gingivobuccal space is possible⁴

Interventions: 

Gauze / Packing

• Simple and low-cost intervention
• Fold a stack of 2x2s and instruct patient to bite down for at least 20 minutes

Lidocaine with Epinephrine

• Lidocaine 1% with epinephrine: Approximately 1-3 mL
• Infiltrate the tissue until you see adequate blanching of the extraction site
• Have patient bite down on soaked gauze to create an additive effect of vasoconstriction and mechanical pressure
  • The anesthetic effect from the lidocaine will make it easier for the patient to bite down on the gauze

Tea Bag

• Black tea bags contain the highest concentration of tannins⁵
  • Tannins are hemostatic and have mild antiseptic properties
• Place tea bag in boiling water for 2-3 minutes, allow to cool, then place on extraction site for 5 minutes

Tranexamic Acid

• Commonly used in three different ways to achieve hemostasis
• Mouthwash
  • Has shown benefit for post-procedural bleeding in patients with multiple tooth extractions while on a DOAC⁶
  • Often used pre-procedurally and post-procedurally for prophylaxis
  • Have patient gently rinse their mouth with 5-10mL of 5% TXA solution for 2 minutes and then spit out the solution while being careful not to dislodge any formed clots⁷
• Gauze soaked in TXA
  • Soak 2×2 or 4×4 gauze in a solution of the IV preparation of TXA and place over extraction site with moderate pressure from patient biting down to keep it in place⁸
  • Reassess for hemostasis in 10-20 minutes
• TXA Paste
  • Almost non-existent literature but is a low-cost alternative to IV TXA solution.
  • Crush three 650mg TXA tablets and add small aliquots of about 0.5mL sterile water until a fine paste is achieved. Apply for 20-30 minutes before reassessment and removal of paste^9-10

Combination Topical Thrombin & Gelatin Foam

• Trade name is FloSeal
• Can be applied over extraction site in order to provide the scaffolding and thrombin to initiate clot formation¹¹

Embolization

• Reserved for only the most severe and refractory bleeding when concern for hypovolemic shock and airway compromise are evident
• Rare cases of AVMs causing persistent and brisk bleeding from dental extraction
• Consult IR and OMFS for definitive management and admission

Pearls:

• Ask about antiplatelets, anticoagulants, and recent INR
• Start with gauze and gentle pressure with lidocaine and epinephrine or a tea-bag
• Escalate to your preferred method of TXA
• FloSeal may be difficult to obtain but can be applied easily
• Life-threatening bleeding should be considered for IR embolization

Further Reading:

FOAM:

• https://www.aliem.com/trick-trade-topical-tranexamic-acid-paste-hemostasis/
• http://www.emdocs.net/managing-dental-trauma-emergency-department/
• http://www.emdocs.net/em3am-bleeding-disorders/
• https://rebelem.com/topical-tranexamic-acid-epistaxis-oral-bleeds/

References:

1. https://www.news-medical.net/health/Universal-Numbering-System-for-Teeth.aspx
2. https://www.simplydentalchatswood.com.au/tooth-extraction-explained-step-by-step/
3. Kumbargere Nagraj S, Prashanti E, Aggarwal H, Lingappa A, Muthu MS, Kiran Kumar Krishanappa S, Hassan H. Interventions for treating post-extraction bleeding. Cochrane Database Syst Rev. 2018 Mar 4;3(3):CD011930. doi: 10.1002/14651858.CD011930.pub3. PMID: 29502332; PMCID: PMC6494262.
4. Nilesh K, Shah S, Gautam A, Thorat S. Uncontrolled bleeding during tooth extraction from an undiagnosed arteriovenous malformation. BMJ Case Rep. 2021 Aug 26;14(8):e236983. doi: 10.1136/bcr-2020-236983. PMID: 34446508; PMCID: PMC8395353.
5. Steele SK. Controlling gingival bleeding with tea bags. Oncol Nurs Forum. 1992 May;19(4):663. PMID: 1603679.
6. Ockerman A, Miclotte I, Vanhaverbeke M, Vanassche T, Belmans A, Vanhove J, Meyns J, Nadjmi N, Van Hemelen G, Winderickx P, Jacobs R, Politis C, Verhamme P. Tranexamic acid and bleeding in patients treated with non-vitamin K oral anticoagulants undergoing dental extraction: The EXTRACT-NOAC randomized clinical trial. PLoS Med. 2021 May 3;18(5):e1003601. doi: 10.1371/journal.pmed.1003601. PMID: 33939696; PMCID: PMC8128271.
7. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2)(suppl):e326S-e350S. doi:10.1378/chest.11-2298[PubMed 22315266]
8. Noble S, Chitnis J. Case report: use of topical tranexamic acid to stop localized bleeding. Emergency Medicine Journal 2013;30:509-510.
9. Coetzee MJ. The use of topical crushed tranexamic acid tablets to control bleeding after dental surgery and from skin ulcers in haemophilia. Haemophilia. 2007 Jul;13(4):443-4. doi: 10.1111/j.1365-2516.2007.01479.x. PMID: 17610565.
10. https://www.aliem.com/trick-trade-topical-tranexamic-acid-paste-hemostasis/
11. Schoenecker JG, Johnson RK, Fields RC, et al. Relative purity of thrombin-based hemostatic agents used in surgery. J Am Coll Surg 2003; 197:580.
12. Chapter 179. Post-Extraction Bleeding Management. In: Reichman EF. eds. Emergency Medicine Procedures, 2e. McGraw Hill; 2013. Accessed August 24, 2022. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=683&sectionid=45343828