Establishing hemostasis post-extraction

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One of the most common clinical scenarios that I am faced with in daily dental practice is the management of patients who have alterations to their coagulation. These patients present either medically anticoagulated for reasons such as atrial fibrillation or a replaced heart valve,

or for hypercoagulation, including deep vein thrombosis, pulmonary embolism, or stroke. More rarely, patients can present with inherited coagulopathies such as hemophilia or von Willebrand’s disease, both of which leave patients at increased risks of intra- and postoperative bleeding.

 

Appropriate perioperative management of the anticoagulated patient requires a basic understanding of the patient’s underlying medical history for which his or she is anticoagulated. Many patients will tolerate either a reduction or complete discontinuation of their anticoagulation medications for a limited time, allowing a more ideal environment to perform oral surgical procedures.

 

Next, we must understand the basic pharmacology of the various forms of anticoagulation therapies. Not only is it important to understand the function of these medications, but also the effective half-lives that allow guidance on when to discontinue and when to resume these medications. Coumadin, which functions by blocking the extrinsic coagulation pathway, has an effective half-life of three days. Therefore, if these medications are going to be discontinued, we can expect that the patients’ coagulation process will be at an appropriate level three days after discontinuation. Aspirin or Plavix (clopidogrel), both of which work by interfering with platelet adhesion, are irreversible and last the life of the blood platelet, thus they must be discontinued seven days prior to surgery if we are to expect normal platelet function. Some newer medications, such as Eliquis (apixaban) which blocks factor X, or Pradaxa (Dabigatran etexilate) which reversibly inhibits thrombin, have shorter half-lives and therefore may be stopped 12 to 24 hours before surgery and resumed 12 hours after surgery once stable clotting has occurred.

 

I will often speak with the patient’s physician to come up with the best perioperative management strategy. With that in mind, there is always a risk of a thromboembolic event when the anticoagulation therapy is discontinued. Consequently, I will often have my patients maintain their normal medication if I am performing a minor procedure such as three to four extractions or a dental implant. For major surgery, patients will need to come off of their medications and occasionally will need to be managed with a short-acting anticoagulant such as Lovenox injections, which they can then stop the night before surgery.

There are several intraoperative techniques that can be used to help reduce the incidence of prolonged bleeding. I pay particular attention to the removal of all granulation tissue, which tends to increase bleeding even in those patients who are not anticoagulated. In addition, avoiding undue trauma or tears to soft tissues will help minimize unwanted bleeding. Good suctioning to make certain the extraction site is clean followed by adequate irrigation will help. Once all tissue is cleaned out, I will routinely pack the socket with a hemostatic plug. This can be gel-foam, surgical, Avitene, collagen plug, or Helistat. Various vendors sell these products, and they will often be precut for single use.

Not only do these products provide a resorbable scaffold to stabilize a clot, but they also apply direct pressure. This is usually followed by the placement of a suture and additional direct pressure with a gauze pack. I will typically have my patients stay in the office for an extra five or 10 minutes to confirm hemostasis prior to discharge. It is important that patients maintain pressure on the wound initially, and I ask my patients to avoid any hot foods or liquids that could lead to vasodilation and increase the risk of bleeding. Also, I ask them to avoid rinsing their mouths for 24 hours as the mechanical pressure can loosen a clot and cause prolonged bleeding. Certainly if I have patients who are smokers, I strongly encourage them to avoid smoking for 24 hours as the heat from the cigarette and the mechanics of smoking, which creates a negative pressure in the mouth, are both deleterious to stable clotting.

Should the patient call back with postoperative bleeding, I will have him or her take some routine steps to try to promote hemostasis. First, I ask the patient to bite down on gauze for 20 minutes. If the bleeding persists, I ask the patient to moisten a tea bag in cool water, wrap that in a gauze, and bite for an additional 20 minutes. Tea contains tannic acid, which helps with clotting. If bleeding is persistent despite these measures, I will have the patient return to the office. It is not uncommon for anticoagulated patients to form incomplete clots, commonly called “liver clots.” Often the patient states that the bleeding begins and then discontinues, only to begin again after several hours. Management consists of local anesthesia with epinephrine assuming the medical condition will allow, followed by irrigation of the faulty clot, suctioning, and then repacking and suturing to allow a more stable clot to form.

Once the patient has formed a stable clot, I typically ask him or her to resume normal preoperative medications. Anecdotally, I have found by performing clean surgery, managing soft tissues appropriately, and packing and suturing the wounds, then having the patient follow standard postoperative measures, prolonged postoperative bleeding is a rare occurrence. Should it happen, I do not hesitate to have my patients return to the office for evaluation and management.

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