The document discusses management of intraoral bleeding during surgery. It covers hemostasis mechanisms, factors influencing surgical bleeding, adverse effects of bleeding, characteristics of ideal hemostatic agents, and various methods of hemostasis including mechanical, thermal, and chemical approaches. Common hemostatic agents discussed include adrenaline, bone wax, thrombin, gelfoam, and fibrin glue. Proper agent selection and application technique are important to control bleeding during oral surgery procedures.

1. GOOD
MORNING…..
1

2. Management of intraoral
bleeding during surgery
seminar on
PRESENTER: PUNIT
DEPARTMENT OF PERIODONTICS 2

3. CONTENTS
 INTRODUCTION
 HEMOSTATSIS
 ADVERSE EFFECTS OF SURGICAL BLEEDING
 FACTOR INFLUNCING SURGICAL BLEEDING
 WHY USE HEAMOSTATIC AGENTS
 CHARECTERISTICS OF IDEAL HEMOSTATIC AGENTS
 METHODS OF HEMOSTATIS
 CONCLUSION
 REFERENCE
3

4. Introduction 4

5. There are 3 mechanisms that work together to stop the flow of blood.
They are :-
•Vasoconstriction
•Platelet plug formation
•Clotting of blood
Hemostasis 5

6. Vasoconstriction
6

7. Platelet plug formation
7

8. Clotting of blood
8

9. COAGULATION CASCADE
9

10. 10

11. The best management of intraoperative hemorrhage is prevention.
This includes a thorough preoperative patient history, necessary
medical consults, familiarity with managing patients with possible bleeding diathesis,
meticulous intraoperative technique, and appropriate postoperative instructions, care,
and followup.
11

12. During oral surgical procedures, persistent minor oozing of blood is common,
although occasionally a bleeding episode prevents the continuation of the
procedure and requires immediate attention.
The usual sources for this intraoperative complication are incision into an area
of granulomatous tissue, vessels in the periosteum or mucosa, or encountering
nutrient arteries in the alveolar bone.
12

13. The dentist should be familiar with the range of methods, techniques,
materials, and their application during different types of bleeding episodes.
Having a broad knowledge of the management approaches will allow the
clinician to know when to apply a particular approach.
One of the more common methods of intraoperative hemorrhage control
involves the use of a topical hemostatic agent
13

14. • Type of procedure
• Patient position
• Surgical incisions
• Exposed bone
• Large surfaces of exposed
capillaries
• Unseen sources of bleeding
• Tissues that cannot be sutured or
low-pressure suture lines
• Adhesions stripped during surgery
Procedural
factors
• Specific anatomical considerations
• Medications (eg. Anticoagulants)
• Coagulopathies
• Platelet dysfunction or deficiency
• Fibrinolytic activity
• Coagulation factor deficiencies
• Medical conditions
• Nutritional status
Patient
factors
Factors influencing Surgical bleeding
14

15. • Visual obstruction of the surgical field
• Need for blood transfusions
• Reduction in core temperature
• Thrombocytopenia
• Hypovolemic shock
Adverse effects of Surgical bleeding
15

16. 16

17. Factors in Choosing a
Hemostatic Agent
17

18. Characteristics of an Ideal hemostatic agents
for clinical use:
(1) capability to stop large vessel arterial and venous bleeding within minutes
of application when applied to an actively bleeding wound through a pool
of blood;
(2) no requirement for mixing or pre-application preparation;
(3) simplicity of application
(4) light weight and durable;
(5) long shelf life in extreme environments;
(6) safe to use with no risk of injury to tissues or transmission of infection;
(7) cost-effective
18

19. The techniques for local hemostasis may be
classified as
Mechanical
Thermal
Chemical
19

20. Mechanical methods
oPressure
oUse of hemostats
oSutures and ligation
oEmbolisaton of vessels
20

21. •Application of pressure basically counteracts hydrostatic pressure within the
bleeding vessel until such time that a clot can form and occlude the bleeding
orifice.
• Pressure is usually able to control most of the hemorrhages.
•Pressure should be appied directly over the bleeding site firmly over a guaze
packfor atleast five minutes.
Pressure
21

22. •Use of hemostats (also called a hemostatic clamp, arterial forceps,)
•Haemostat (mosquito,artery) forces are specially designed to catch bleeding
points in the surgical area.these can be straight or curved.
•Curved haemostats are used more frequently,because of their versatility and
ease in tying the ligature around the tip of forceps.
Hemostats
22

23. •Transected blood vessel may need to be tied with the help of a ligature.
•When large artery needs to be ligated,nonabsorbable material like 3-0 black
silk is preferred.
•Smaller vessels can be ligated with 3-0 catgut,or polyglactin.
•Large pulsatile artery ligated with double transfixation.
Sutures and ligation
23

24. Embolization of the vessels
 With the help of angiography ,the exact bleeding point can be localized.
 Agents which can be used for embolization include steel coils, polyvinyl
alcohol foam , gel foam, silicon spheres, methyl methacrylate.
 These particles are placed via a catheter superselectively into the bleeding
vessel .
24

25. Thermal agents
oCautery
oElectrosurgery
oCryosurgery
oArgon-beam coagulator
oLasers
25

26. Heat achieves haemostasis by denaturation of proteins which results in coagulation
of large areas in the tissue. In cauterization, heat is transmitted from the instrument
by conduction directly to the tissues.
Cautery
26

27. In electrocautery,heating occurs by induction from an alternating current source.it
is an effective and convenient way of controlling hemorrhage.
Electrocautery can be applied directly to bleeding point or after catching the
bleeding point with haemostat.then cautery pont is touched to the haemostat
causing of the vessel through the action of heat.
Electrosurgery
27

28. oThe argon beam coagulator (ABC) delivers
radiofrequency electrical energy to tissue across a jet of
argon gas, providing noncontact, monopolar,
electrothermal hemostasis.
oIn this ,coagulator monopolar current is transmitted to
the tissues through the flow of argon gas which allows
bleeding from vessels that are smaller than 3mm in
diameter to be controlled without use of haemosats or
ligatures.
Argon-beam coagulator
28

29. Lasers usually result in bloodless surgery ,as these effectively coagulate the small
blood vessels during cutting of tissues
Argon laser provides excellent hemostasis and coagulation
Lasers
29

30. Chemical methods
I. Astringent agents and styptics
II. Bone wax
III. Thrombin
IV. Gelfoam
V. Oxycel
VI. Surgicel
VII. Fibrin glue
VIII. Adrenaline
IX. others
30

31. •Adrenaline or epinephrine,applied topicaly induces vasoconstriction and thus
helps in acheiving hemostasis.
• Extensive application or undiluted preparation can cause systemic effects
therefore ,care should be exercised while using adrenaline.
•It can also be injected along with local anesthetic in a concentration of 1:80,000
to 1:2,00,000
Adrenaline
31

32.  Chemical agents vary in their hemostatic actions.
 Monsel’s solution contains Ferric sulphate and it acts by precipitating proteins.It is
quite effective in arresting capillary bleeding.
 Tannic acid also helps in precipitating proteins.
 Mann hemostatic is a mixture of tannic acid,alum and chlorbutamol.
 Silver nitrate and ferric chloride are used in case of minimal capillary bleeding
Astringent agents and styptics
32

33. Is a mixture of beeswax (70%) and Vaseline (30%).
Used to help mechanically control bleeding from bone surfaces during
surgical procedures.
It is a non-absorbable material,becoming soft and malleable in the hand
when warmed an is most commonly supplied in sterile sticks
Bone wax
33

34. Topical use of thrombin acts by converting fibrinogen into.fibrin clot
Topical thrombin indicated as an aid to hemostasis whenever oozing blood and minor
bleeding from capillaries and small venules is accessible and control of bleeding by
standard surgical techniques (such as suture, ligature or cautery) is ineffective or
impractical.
Thrombin
34

35. •Gelfoam sterile powder is a fine, dry, heat-sterilized light powder prepared by
milling absorbable gelatin sponge.
•It is a water-insoluble,off-white, nonelastic, porous, pliable product
•While its mode of action is not fully understood, its effect appears to be more
physical than the result of altering the blood clotting mechanism.
Gelfoam
35

36. Gelfoam/Surgifoam
Absorbable Gelatin
SURGIFOAM Absorbable Gelatin Powder
GELFOAM Absorbable Gelatin Sponge
SURGIFOAM Absorbable Gelatin Sponge
36

37. 37
When not used in excessive amounts,Gelfoam is absorbed completely,
with little tissue reaction
When placed in soft tissues, Gelfoam is usually absorbed completely in
from 4 to 6 weeks, without inducing excessive scar tissue.
This absorption is dependent on several factors, including:
•The amount used
•Degree of saturation with blood or other fluids
•Site of use.

38. Usage 38
Gelfoam should be cut to the minimum size
required to attain hemostasis. Gelfoam may be
applied dry or saturated with a physiologic
saline solution.
When applied dry, Gelfoam should be manually
compressed before application to the bleeding
site.
When used with saline, Gelfoam should be
soaked in the solution, then withdrawn,
squeezed between gloved fingers to expel air
bubbles present in the interstices, replaced in
saline, and kept there until needed.
Gelfoam should be applied to the bleeding
surface and held in place with moderate
pressure until hemostasis is attained
It is not necessary to apply suction to
Gelfoam, since Gelfoam will draw up blood
into its interstices by capillary action

39. •Gelfoam should not be used in closure of skin incisions because it
may interfere with healing of the skin edges.
•This is due to mechanical interposition of gelatin and is not secondary
to intrinsic interference with wound healing.
•Gelfoam should not be placed in intravascular compartments, because
of the risk of embolization.
Contra-Indications:
39

40. Flowable Gelatin
 Composition(combination of two
independent agents and consists of
bovine-derived gelatin granules coated
in human-derived thrombin that works
in combination to form a stable clot at
the bleeding site)
 Animal-derived gelatin mixed with
thrombin (or saline) in a flowable
consistency
 Mode of action
 Gelatin provides a matrix for
platelet adhesion and
aggregation
 Thrombin aids in fibrin clot
formation
 Will not work if the area is not
actively bleeding
40

41. Flowable Mechanism of Action
• Applied to the tissue surface at the base of the lesion. Its
granules fill the wound and conform to its shape.
• Granules expand approximately 20% within about 10
min and restrict the flow of blood. Blood that percolates
through the spaces is exposed to high concentrations of
thrombin.
• A clot forms around the matrix provided by the
granules and remains in place at the tissue surface.
41

42. Surgiflo
42

43. Oxidized regenerated cellulose is also known as Surgicel or Oxycel in its
commercial forms is derived from alpha-cellulose that is actually plant-based.
Oxycel is an absorbable haemostat that has been used to control bleeding safely,
simply and effectively
Oxycel or Surgicel
43

44. Provides a matrix for platelet adhesion, accelerating
the formation of the platelet plug that will form the
foundation of the fibrin clot
Creates an area of low pH causing localized
vasoconstriction
Oxidized Regenerated Cellulose (ORC) absorbs
blood and becomes a gel covering the site of vessel
injury
How Does SURGICEL Work? 44

45. Why is SURGICEL Bactericidal?
This pH lowering effect remains until
the material is fully absorbed (7-14
days)
Under acidic conditions, bacteria
become less active
This causes localized area of low pH
(3.4-3.7)
Contact with moisture triggers the
breakdown of cellulose and the release
of cellulosic acid
45

46.  Conforms to wound site, minimal sticking to gloves or instruments
 Effective hemostasis for classic 6-8 minutes, Nu-knit 3-5 minutes, fibrillar 3-4
minutes
 No immunogenicity potential, bactericidal
 Absorption within 7-14 days (depending on amount used, degree of saturation
with blood)
46

47. •Fibrin glue(also called Fibrin sealant) is a formulation used to create a fibrin clot
aiding in hemostasis
•It is made up of fibrinogen(lyophilised pooled human concentrate) and
thrombin(bovine, which is reconstituted with calcium chloride) that are applied to
the tissue sites to glue them together.it may also contain aprotinin,fibronectin and
plasminogen
•Thrombin is an enzyme and converts fibrinogen into fibrin monomers between
10 and 60 seconds giving rise to a three-dimensional gel.
Fibrin Glue
47

48. Fibrin glue is "Fibrin Fibronectin Sealing System (FFSS)"
It is available as two component system: first component contains highly concentrated
fibrinogen, factor XIII, fibronectin, and traces of other plasma proteins. The second
component contains thrombin, calcium chloride, and antifibrinolytic agents such as
aprotinin.
Mixing of two components promotes clotting with the formation and cross-linking of
fibrin.
48

49. When periodontal plastic surgical procedures done
or implants placed in esthetic zone, fibrin sealants
may be variable alternative to closing flaps with
sutures and with histologic benefits
In periodontal plastic surgeries of esthetically
important areas it gives better results than sutures.
49

50. Fibrin Sealants
 EVICEL
 Uses human thrombin (all
human components)
 Low risk of immune reaction
 No aprotinin or tansexamanic
acid
 Prep time <1 minute
 Clear clot
 Spray or drip
 TISSEEL
 Uses bovine thrombin
 Higher risk of immune reaction
 Contains aprotinin
 Prep time 15 minutes
 Cloudy white clot
 Spray (syringe or pressure
delivery) or drip
50

51. Precautions and limitations
1. Fibrin sealant cannot be used in individuals who are known to be
hypersensitive to bovine protein
. 2. Fibrin sealant cannot be indicated for the treatment of massive and
brisk arterial or venous bleeding
3. To avoid risk of allergic anaphylactic reaction and/or thromboembolic
events, which may be life threatening, fibrin sealant should not be applied
intravascularly or into the tissues.
51

52. Tisseel 52

53. Evicel 53

54. Co-Seal and BioGlue most commonly used
Creates a shell over the area applied
Caution not to cover things that will be removed
Synthetic Sealants
BioGlue
 Composed of Glutaraldehyde and purified bovine serum albumin (BSA)
 Binds covalently to tissue surface proteins (won’t work if place on non-protein
surface)
 Supplied with multiple syringe tips as they clot off as soon as there is no active
injection.
54

55. CoSeal
 Composed of two synthetic polyethylene glycols (PEGs) in
hydrogen chloride and sodium phosphate
 When mixed the PEGS form a hydrogel that adheres to
tissue and covalently bonds to itself
 Completely synthetic, no gluteraldehyde
 Swells up to 4 times its volume in 24 hrs and additional
swelling may occur as the gel resorbs
55

56. Chitosan-based dressing
 Chitosan is a biodegradable,nontoxic,complex
carbohydrate derived from chitin(a naturally occuring
substance from zeolites): when the deacetylation of chitin
is above 70% the generic name” Chitosan” is applied
 In the form of an acid salt it has a mucoadhesive activity
 It has a positive charge and it attracts RBCs and Platelets
which have negative charge.
 The freeze-dried Dressing augments its sealing action
 Also offers an antibacterial barrier
56

57. •Hemostatic mechanism is due to activation of thromboplastin formation on
damaged vessel walls and decrease prostacyclin 2 synthesis and facilitates platelet
aggregation. Ethamsylate reduces capillary bleeding in the presence of normal
number of platelets.
•It acts by correcting abnormal platelet adhesion.
•It exerts antihyaluronidase action,improves capillary wall.stability,not stabilize
fibrin(not an antifibrinolytic).
Ethamsylate 57

58. Indications: used in prevention and.treatment of capillary
bleeding in
*menorrhagia
*epistaxis
*hematuria
*after tooth extraction
Efficacy is unsubstantiated
adverse effects like rash are common and blood pressure falls only after IV injection.
Dose: 250-500 mg TDS oral /IV
58

59. Tranexamic acid
 Tranexamic acid 4.8% oral rinse is an antifibrinolytic agent
that stabilizes clots and facilitates clot formation by
competitively inhibiting plasminogen, the enzyme responsible
for activating plasmin.
 It can also be useful as a prophylactic mouthwash in patients
who are on anticoagulant medications which require oral
surgery. It can be used preoperatively, intraoperatively, or
postoperatively to manage bleeding. It is very popular as a
post-operative hemostatic mouthwash.
59

60. Botroclot
Haemocoagulase :- A proteolytic enzyme from venom of South American
viper,Bothrops atorox, A plasma clotting agent for fibrinogen(a haemostatic)
INDICATIONS:
• Topical capillary bleeding & tissue oozing
• Hastens coagulation through multiple actions
• Promotes cosmetically elegant, scarless wound healing
• Arrests bleeding in cuts and wounds
• Surgical incisions
• Post Hysterectomy
• Plastic Surgeries, Skin Grafting (Donor & Receptor
areas)
• Dental Extractions
60

61. Dosage:
Apply 5 to 10 drops or sufficient quantity to cover the wound
completely.
61

62. Conclusion
Control of bleeding is the most important integral part of any surgical
treatment procedure. Proper prior evaluation of the patient & complete
medical and family history are very much essential to overcome intra
operative & post operative bleeding arising from undetected bleeding
disorders
62

63. References
1. Contemporary Oral and Maxillofacial Surgery – Peterson
2. Textbook of Pathology – Harshmohan.
3. Textbook of Oral Surgery – Vinod Kapoor
4. Review of hemostatic agents used in dentistry. McBee WL, Koerner KR.
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64. “All Bleeding Stops”
T
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