1. Diagnosis and Management of
Hemorrhage in Oral Surgery
DR MOHAMMAD AKHEEL
OMFS PG

2. What is meant by Hemorrhage ?
Prolonged or uncontrolled bleeding is often
referred to as hemorrhage.
The amount of blood lost as a result of
hemorrhage can range from minimal to
significant quantities.

3. Hemorrhage in Surgery
Hemorrhage can occur to a greater or lesser
degree during all surgical procedures and it’s
management depends upon whether the patient is
hematologically normal or suffers from some
disturbance in the normal clotting mechanism.

4. Hemorrhage in Oral Surgery

5. Hemorrhage in Oral Surgery
The overwhelming majority of patients who
undergo oral surgical procedures are those who
have normal haemostatic mechanism.
Therefore, significant or major hemorrhages are
not that common in oral surgery except in patients
who have a bleeding / clotting disorder or those
who are on anticoagulants.

6. Hemorrhage in Oral Surgery
However, uncontrolled and persistent bleeding
can occur in some healthy patients after dental
extraction.
Therefore, it is still important to achieve proper
hemostasis in all patients during oral surgical
procedures, so as to prevent excessive post-
operative blood loss.

7. Normal Mechanism of Hemostasis
Hemostasis is a complicated process.
It involves a number of events

8. Hemostasis - Normal Mechanism
1. VASCULAR PHASE
2. PLATELET PHASE
3. COAGULATION PHASE

9. VASCULAR PHASE
When a blood vessel is damaged,
vasoconstriction results.

10. PLATELET PHASE
Platelets adhere to the damaged surface
and
form a temporary plug.

11. COAGULATION PHASE
Through two separate pathways, the
Intrinsic and Extrinsic, the conversion of
fibrinogen to fibrin is complete. Fibrin
tightly binds the platelets to form a clot

12. THE CLOTTING MECHANISM
INTRINSIC EXTRINSIC
Collagen Tissue Thromboplastin
XII
XI VII
IX
VIII
X
V FIBRINOGEN
(I)
PROTHROMBIN THROMBIN
(II) (III) FIBRIN

13. HEMOSTASIS
DEPENDENT UPON:
Vessel Wall Integrity
Adequate Numbers of Platelets
Proper Functioning Platelets
Adequate Levels of Clotting Factors
Proper Function of Fibrinolytic Pathway

14. Hemorrhage in Oral Surgery
Hemorrhage following Oral Surgical procedures
can occur due to local or systemic causes.
In healthy patients the postoperative bleeding is
mainly due to local causes.

15. Local causes of hemorrhage in oral surgery
Local causes of hemorrhage originate in either
soft tissue or bone.

16. Local causes of hemorrhage in oral surgery –
Soft tissue bleeding
Soft tissue bleeding is either arterial, venous, or
capillary in nature.

17. Local causes - Soft tissue bleeding in oral surgery
Arterial bleeding is bright red and spurting in nature.
Arteries in the soft tissues at risk during oral surgical
procedures are the lies posterior portion of hard palate)
greater palatine artery and the buccal artery (lies lateral
to the retromolar pad)

18. Local causes - Soft tissue bleeding in oral surgery
Venous blood is dark red in color and flows
steadily and heavily especially if the vein is large .
Capillary bleeding is bright red in color and is
more of a minimal ooze.

19. Local causes – Osseous (Bony) bleeding in oral
surgery
Troublesome bone bleeding originates either from
nutrient canals in the alveolar region, central
vessels, such as the inferior alveolar artery, or
from central vascular lesions (Hemangioma or
Vascular malformation)

20. Systemic causes of hemorrhage in oral surgery
Some patients with heriditary conditions such as
hemophilia, Von Willebrand’s disease are susceptible for
hemorrhage following oral surgical procedures.
Patients with thrombocytopenia (decreased platelet
count) , Leukemia e.t.c., are also at risk of prolonged
bleeding after surgery.
Patients with uncontrolled hypertension.

21. Systemic causes of hemorrhage in oral surgery
Patients with H/O prosthetic heart valve replacement,
Stroke (Cerebrovascular accident) e.t.c., take oral
anticoagulants like Aspirin or Warfarin to prevent the
occurrence of a thromboembolic episode.
These patients are also at risk of prolonged severe
bleeding during and after an oral surgical procedure.

22. Types of Hemorrhage - Primary Hemorrhage
This occurs during the surgery, as a result of injury like
cutting or laceration of the artery or bleeding from
bone.
This also occurs when surgery is done in an infected
area with a lot of granulation tissue.
It can also occur after a very short period of time
immediately after surgery.
This type of bleeding is really normal and can be
controlled easily.

23. Types of Hemorrhage - Intermediate /
Reactionary Hemorrhage
This type of bleeding occurs within a few hours after
surgery.
This type of bleeding occurs as a result of failure of
coagulation to occur (as in patients with systemic
bleeding problems or those on anticoagulants)
Patients who have unknowingly disturbed / dislodged the
clot are also prone for this type of bleeding.

24. Types of Hemorrhage - Secondary Hemorrhage
This occurs after 7 to 10 days after surgery. This is
mainly due to partial division of blood vessel in
combination with infection of the wound (Like patient’s
who undergo radical neck dissection e.t.c.,).
This type of bleeding is not very frequently encountered
after oral surgery procedures.

25. Management of Primary Hemorrhage in Normal
patients
The management of bleeding during surgery (Primary
bleeding) can be achieved by the following means,
(i) Securing / ligation of blood vessels with silk sutures.
(ii) Use of pressure swab to achieve hemostasis.
(iii) Use of electrocautery to achieve hemostasis.
(iv) Use of hemostatic agents like bone wax, surgicel,e.t.c.,
(v) Hypotensive anaesthesia (G.A) and use of
vasoconstrictors in L.A.

26. Local Measures ( Synthetic Materials)
There are several materials that are commercially
available that are used locally for achieving
adequate hemostasis.

27. Local Measures: Surgicel (Oxidised Regenerated
Cellulose)

28. Local measures: Gelfoam with activated thrombin

29. Local Measures: Avitene (Microfibrillar
Collagen)

30. Local Measures:
Etik Collagen (Packed collagen)

31. Local Measures: Tranexamic acid 5%

32. Local Measures: Tranexamic acid 5% in Syringe

33. Local Measures: Irrigation of wound with
Tranexamic acid

34. Local Measures: Suturing the wound

35. Local Measures: Pressure with oral packs

36. Management of Intermediate Hemorrhage in
Normal patients
The management of bleeding that occurs immediately
after surgery (Reactionary bleeding) involves proper
examination of the surgical wound to identify the site
of bleeding (i.e ) from bone or soft tissue.
(i) If bleeding is from bone then the hemostatic agents
like bone wax or gelfoam is usually used.
(ii) If bleeding is from soft tissues then, ligation /
cauterization of blood vessels along with the use of
hemostatic agents like surgicel and suturing of the
wound is carried out.

37. Management of Secondary Hemorrhage in Normal
patients
The management of this type of bleeding that occurs a
few days after surgery involves the removal of any debris
from the wound surface that promotes the infection of the
wound.
Identify the source of bleeding and treat as would be
done in a patient with secondary bleeding.
Surgical stents can be placed over extraction sockets for
stabilization of clot and prevention of wound
contamination.

38. Management of Hemorrhage in patients with
bleeding disorders / and those on anticoagulant
therapy
The usual protocol involved in the treatment of this
group of patients consists of pre-operative blood
investigations and preoperative correction of the
underlying deficiency (Replacement of Clotting factors /
platelets) if any in these patients.
Subsequently, after this appropriate local measures are
used to decrease the chances of post-operative bleeding.

39. LABORATORY EVALUATION
PLATELET COUNT
BLEEDING TIME (BT)
PROTHROMBIN TIME (PT)
PARTIAL THROMBOPLASTIN TIME (PTT)
THROMBIN TIME (TT)

40. PLATELET COUNT
NORMAL 100,000 - 400,000 CELLS/MM3
< 100,000 Thrombocytopenia
50,000 - 100,000 Mild Thrombocytopenia
< 50,000 Severe Thrombocytopenia

41. BLEEDING TIME
PROVIDES ASSESSMENT OF PLATELET
COUNT AND FUNCTION
NORMAL VALUE
2-8 MINUTES

42. PROTHROMBIN TIME
Measures Effectiveness of the Extrinsic Pathway
NORMAL VALUE
10-15 SECS

43. PARTIAL THROMBOPLASTIN TIME
Measures Effectiveness of the Intrinsic
Pathway
NORMAL VALUE
25-40 SECS

44. THROMBIN TIME
Time for Thrombin To Convert
Fibrinogen Fibrin
A Measure of Fibrinolytic Pathway
NORMAL VALUE
9-13 SECS

45. Management of Hemorrhage in patients with
uncontrolled hypertension.
This group of patients need appropriate medical
consultation for initiation of medical treatment to
decrease their Blood Pressure.
Thus once their B.P is controlled, then the bleeding
decreases and with local measures the hemorrhage is
controlled.

47. THANK YOU