Dental Bleed (Diagnosis & Treatment)
Ears, Eyes, Nose, and Throat
Most oropharyngeal bleeds are secondary to trauma or dental procedures such as tooth extractions (1). Post-operative bleeding can occur up to 6 days after a procedure (2). Due to the risk of thromboembolism, many patients on anticoagulation remain on their medications and can pose an increased risk of bleeding (2).
- Volume status – assess for signs of shock.
Assessment of airway patency is important with an oropharyngeal bleed. This includes:
- Swallowing ability.
- Ability to clear secretions or blood.
- Subjective foreign body sensation in the throat or airway.
An intraoral assessment includes:
- Inspection for dental fractures.
- Palpation of teeth for instability or tenderness.
- Intraoral tissue inspection for lacerations, abrasions, ecchymoses, foreign bodies, tooth fragments, edema, masses, or signs of infection) and palpation (gingiva, buccal mucosa, tongue, frenulum, tonsils, uvula).
Most oropharyngeal bleeds are self-limited.
- Fluid resuscitation or administration of blood products if patient has signs of shock secondary to blood loss.
- Constant direct pressure for a minimum of 20 minute.
- Gelfoam or Surgicel packing into the site.
- Topical tranexamic acid 500 mg (5 ml) as a soaked pledget – hold pressure on the site of bleeding or ask patient to bite on the gauze or cotton pledget.
- Local injection of lidocaine with epinephrine to vasoconstrict the site, followed by direct pressure.
- Suture of extraction site with nylon or prolene in figure 8 fashion to achieve hemostasis.
- Reversal of any anticoagulation.
- Inherent coagulopathy and/or an antiplatelet agent should be considered if there is ongoing bleeding.
- If the above measures are unsuccessful, consult an oral surgeon and/or interventional radiology for possible surgical management or embolization as there may be an injury to a blood vessel.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Gelfoam or Surgicel can be used to facilitate hemostasis for dental bleeds.
Apply pressure with a gauze or cotton pledget soaked in tranexamic acid for dental bleeds.
Local injection of lidocaine with epinephrine if there is ongoing dental bleeding after direct pressure has already been tried.
Investigate for coagulopathy only if the bleeding is refractory to first- and second-line management.
Hammel JM, Fischel J. Dental emergencies. Emerg Med Clin N Am. 2019; 37(1): 81-93.
Poznanski SL. Dental emergencies in the ED. Emerg Med Rep. 2015; 26(21).
Benko KR. Chapter 64 – Emergency Dental Procedures. In: Roberts JR, Custalow CB, editors. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7th ed. Philadelphia: Elsevier; 2019: 1384-1404. Accessed January 5, 2022. https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323354783000646?scrollTo=%23hl0000668
Engelen, Eveline T, Schutgens, EG Roger, Mauser-Bunschoten, Evelien P, van Es, JJ Robert, van Galen, PM Karin. Antifibrinolytic therapy for preventing oral bleeding in people on anticoagulants undergoing minor oral surgery or dental extractions. Cochrane Database of Systematic Reviews. 2018;(7). Available from EBM Reviews – Cochrane Database of Systematic Reviews at http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=coch&NEWS=N&AN=00075320-100000000-10704. Accessed January 16, 2022.
Kanaa MD, Whitworth JM, Corbett IP, Meechan JG. Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block. Int Endod J. 2009;42(3):238-246
Laino L, Cicciu M, Fiorillo L, Crimi S, Bianchi A, Amoroso G, Monte IP, Herford AS, Cervino G. Surgical risk on patients with coagulopathies: guidelines on hemophiliac patients for oromaxillofacial surgery. Int J Environ Res Public Health. 2019; 16(8): 1386. Accessed Jan 17, 2022. doi: 10.3390/ijerph16081386.
Hsieh JT, Klein K, Batstone, M. Ten-year study of postoperative complications following dental extractions in patients with inherited bleeding disorders. Int J Oral Maxillofac. 2017; 46(9): 1147-1150. Accessed Jan 17, 2022. https://doi.org/10.1016/j.ijom.2017.04.016.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Jan 25, 2022
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