Anticoagulants and dentistry
Achieving haemostasis

For patients on anticoagulants/antiplatelets, it is important that bleeding has completely stopped before they leave. Because of the chance of restarting, and particularly with high risk procedure, strongly consider the use of oxidised cellulose gauze, collagen sponge, sutures. If it starts later, these will be needed anyway.

Managing a bleeding socket in the practice

To stop a soft tissue bleed from the gingiva around the socket immediately after a simple extraction, a bite pack alone will often suffice for a patient not on anti-clotting agents.

Biting on a carefully placed pack will increase the pressure in the gingival tissue, and this pressure stops the gingival bleeding long enough for a clot to form.

Bleeding from the bone into the socket will initially continue, but by covering the socket the pack prevents blood from escaping, and the trapped blood here also clots.

Ideally, a patient will bite for 10 minutes on a wet pack. Although the blood will clot more quickly than this, the extra time allows the clot to develop some strength.

A wet pack will not stick to the clot, so when the pack is removed there will be no disturbance.

When the bleeding won't stop

If gingival bleeding will not stop, or as a preventative measure, a suture can help. When the suture is drawn tight, it increases the pressure in the gingival tissue (the socket "flaps"). This pressure stops the bleeding. Care must be taken however not to over-tighten the suture.

In this video, the sutures are looped from buccal to lingual and back to buccal. This ensures the knots are buccal and can't move to where the tongue might fiddle with them. This "mattress" suture technique applies the pressure evenly over a large area.

To treat or prevent bone bleeding, one can place an "oxidised cellulose dressing" (for example Surgicel) or a collagen sponge directly into the socket. As soon as it is placed, on contact with the moisture in the socket it forms a thick gel.

If using collagen sponge, be aware that collagen is an animal product and some people may not want this.

Oxidised cellulose dressings stop bleeding by accelerating platelet aggregation and helping the blood clotting process to start. The fibres are able to absorb up to seven times their own volume in blood. When saturated the oxidised cellulose swells into a gelatinous mass.

Oxidised cellulose is naturally acidic and it is this acid that starts to break down the blood cells, triggering the clotting process in the body. The acid also creates a hostile environment for most bacteria, potentially preventing infection.

The dressing is ideally held in place with a suture.

How much prevention?

If the patient is on anti-clotting medication, has a history of bleeding after extractions, or their medical history / medications suggest there might be a problem, the use of cellulose gauze and suturing is considered wise. Most dental care professionals have experienced many patients returning, having had bleeding later in the day of the extraction. There is accordingly a strong argument that the majority of extractions should routinely be cellulose-packed, sutured, or both.