This document discusses hemorrhage in oral surgery, including: - Defining hemorrhage as prolonged or uncontrolled bleeding. - Local causes of hemorrhage from soft tissues or bone during oral surgery procedures. - Systemic causes like bleeding disorders or anticoagulant use. - Types of hemorrhage including primary, reactionary, and secondary bleeding. - Management techniques for primary hemorrhage in normal patients including ligation of vessels, cautery, hemostatic agents, and hypotensive anesthesia.

1. 1
Hemorrhage

3. 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.

4. 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.

5. RELEVANCE
1)Oral soft tissues, maxilla & mandible -highly vascular
2)Extraction leaves open wound- allows oozing
3)Impossible to apply pressure during procedure
4)Tongue interference-dislodges clot-secondary bleeding and
negative pressure by sucking
5)Salivary enzymes may lyse clot formation

6. • 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.

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

8. Coagulation factors
Clotting factor Synonyms
Factor I Fibrinogen
Factor II Prothrombin
Factor III Tissue factor(tissue
thromboplastin)
Factor IV calcium
Factor V Pro-accelarin(labile factor)
Factor VII proconvertin/ serum
prothrombinconversion
accelarator(SPCA)
Factor VIII Anti hemophilic factor-A
Factor IX Christmas factor(anti hemophilic B)
Factor X Stuart power factor
Factor XI Anti hemophilic-C/PTA
Factor XII Hageman factor
Factor XIII Fibrin stabilizer factor

9. Hemostasis - Normal Mechanism

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

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

12. 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.
COAGULATION PHASE

13. THE CLOTTING MECHANISM
INTRINSIC EXTRINSI
C
PROTHROMBIN THROMBIN
FIBRINOGE
N
FIBRIN(II) (III)
(I)
V
X
Tissue ThromboplastinCollagen
VII
XII
XI
IX
VIII

14. HEMOSTASIS
DEPENDENT UPON:

15. • 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.

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

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

18. • 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)

19. 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.

20. 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)

21. Systemic causes of hemorrhage in oral surgery
• Some patients with hereditary 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.

22. 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.

23. • Medication: divided into 5 groups-5 A’s
• Aspirin-interferes with platelet formation,prolonged
bleeding due to decreased platelet aggregation and platelet
plug formation .
• Anticoagulants-given to thin their blood to prevent intra
vascular coagulation,e.,.MI.CVA,pulmonary emolism

24. • Antibiotics-(Broad spectrum)causes changes in intestinal
flora which may decease vitamin k production
• Alcohol-prolonged consumption of alcohol may lead to
cirrhosis of the liver-decreased production of coagulation
factors.

25. • Anticancer drugs-interferes with haematopoetic system and
reduces the no.of circulatory platelets(increased bleeding
due to decrease number of platelets)
• Enquire about hypertension and drugs etc.

26. Types of Hemorrhage
26

27. 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.

28. Intermediate / Reactionary Hemorrhage
This type of bleeding occurs within 24 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.

29. Follows primary
CAUSES
-slippage of sutures
-dislodgement of blood clot
-cessation of reflex vasospasm
occurring within 8hrs after stoppage of primary
hemorrhage due to loose bony fragments, calculus,
granulation tissue in socket
Precipitating events- rise in BP, vomiting, cough, restlessness
29

30. 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.

31. Measurement of acute blood loss
Measuring blood loss
1. Swab weighing 1gm =1ml
2. Hb level
3. Measuring CVP

32. MANAGEMENT OF PRIMARY
HEMORRHAGE IN NORMAL
PATIENTS
32

33. MANAGEMENT OF HEMORRHAGE
• Use hemostatic agents-local/systemic
• Local hemostatic measures:
-mechanical
-thermal
-chemical
• Systemic measures
- Hypotensive anesthetics

34. 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.

35. Use of hemostats
• Mosquito Artery-straight & curved(halested’s)is mandatory.
• Moderate sized artery require clamping.
• Lingual and inferior dental artery cannot be clamped-
numbness

36. After clamping ,tying with 3-0 catgut to hold the bleeding
points.
• Sutures and ligatures:
Transected blood vessels need to be tied with ligatures.
Large pulsating artery-non absorbable 3-0 black silk
Small artery –3-0 catgut or polyglatin

39. • Embolization of vessels
With angiography bleeding site is found
Agents-gelfoam,alcohol foam,
methylmeth acrylate

40. Thermal Agents:
• Cautery:
Heat achieves hemostasis by denaturation of protiens-coagulation
of large areas of tissues,e.g.,.electrocautery,ball burnisher

41. • Electrosurgery:
Occurs by induction from alternating current source-cautery point
-the point is touched to achieve hemostasis and sealing of vessel
-burning smell indicates tissue destruction
-not for large vessels.

42. • Lasers:
Bloodless surgeries,effectively coagulate small blood vessels

43. Chemical Agents:
• LOCAL:
• Astringent and styptics:
Tannic acid precipitates protein and causes clot formation(home
remedy-tea bags)
Silver nitrate and ferric chloride in capillary bleeding

44. • Bone wax:
Bleeding from bone.
Ingredients:beeswax-7 parts
olive oil-2 parts
phenol-1 part
Acts by mechanical occlusion of bony
canal .
Less qty to be used –wax granuloma

45. • Gelfoam:
Made from gelatin and sponge like
On contact with
blood,absorbs,swells up,exerts
pressure-acts as a scaffold for
fibrin network and is absored by
phagocytosis

46. • Oxygel:
Oxidized cellulose on application releases cellulosic acid-affinity for
hemoglobin-formatoon of artificial clot(not for epidermal
surface-produces acid)

47. • Surgicel:
Glucose polymer based sterile knitted fabric prepared by
oxidation of regenerated cellulose-depends on binding of
hemoglobin to oxycellulose allowing the dressing to expand to
gelatinous mass
Resorbs within a month.

48. • Fibrin glue:
Biological adhesive containing thrombin,fibrinogen,factor XII
• Adrenalin:applied topically,induces vasoconstriction,gauze pack
soaked.
1:1ooo
Extensive use –systemic complication e.g.,.cardiac pt,HT pt.

49. Systemic Agents:
• Whole blood:
Excessive blood loss-hypovolemic shock,indication for whole
blood transfusion(fresh blood-donation within 2 yrs)
Screen for HIV,HbS etc

50. • Platelet rich plasma:
Adhered to platelet level.
Infusion quickly via short i.v transfusion set.
• Fresh frozen plasma:
Unit(150 ml)fresh frozen plasma has all coagulation factors.

51. • Cryoprecipitate:15 ml vial of cryoprecipitate contains 100 mg of
factor VIII.
• Ethamsylate:decreases capillary bleeding

52. HYPOTENSIVE ANESTHESIA
• Applied when working on GA to
reduce bleeding during operation.
• BP lowered by anesthetist and
bleeding is reduced
• Disadv: arteries may be cut without
obvious bleeding and not tied with
catgut
• Damaged vessels bleed profusely
post surgically, risk of thrombosis

53. Vasoconstriction:
• Prolonged anesthetic effect and
bloodless field to reduce capillary
bleeding under GA.
LA 1:80,000 adrenalin with
halogenated anesthetic agent
• Disadv:may produce cardiac
arrythmias,local tissue cyanosis and
acidity
Post op hematoma formation.
Felypressin used not more than 8-10
ml in adults.

54. Synthetic Materials
There are several materials that are commercially available that are used
locally for achieving adequate hemostasis.

55. Surgicel (Oxidised Regenerated Cellulose)

56. Gelfoam with activated thrombin

57. Avitene (Microfibrillar Collagen)

58. Etik Collagen (Packed collagen)

59. Tranexamic acid 5%
Irrigation of wound
with Tranexamic acid

60. Suturing the wound

61. Pressure with oral packs

62. 62
MANAGEMENT OF INTERMEDIATE
HEMORRHAGE IN NORMAL
PATIENTS

63. 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.

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

65. PLATELET COUNT
NORMAL 1,00,000 – 4,00,000 CELLS/MM3
< 1,00,000 Thrombocytopenia

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

67. PROTHROMBIN TIME
Measures Effectiveness of the Extrinsic PathwayMeasures Effectiveness of the Extrinsic Pathway
NORMAL VALUENORMAL VALUE
10-15 SECS10-15 SECS

68. PARTIAL THROMBOPLASTIN TIME
Measures Effectiveness of the Intrinsic Pathway
NORMAL VALUENORMAL VALUE
25-40 SECS25-40 SECS

69. THROMBIN TIME
Time for Thrombin To Convert
Fibrinogen Fibrin
A Measure of Fibrinolytic Pathway
NORMAL VALUENORMAL VALUE
9-13 SECS9-13 SECS

70. 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.

71. 71
Hemostasis
“Life in the Balance”
Bleeding
to Death
Trauma
Major Surgery
Hemophilia
Clotting
to Death
Stroke
MI
Thrombosis
Lawson JH, et al. Semin Hematol. 2004;41(suppl 1):55-64.

72. References:
• Textbook of Medical Physiology – Guyton
• Principles of Internal Medicine – Harrison’s.
• Principles and Practice of Medicine – Davidson.
72