Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 7  |  Issue : 2  |  Page : 132-135

Massive clot formation after tooth extraction


Department of Oral and Maxillofacial Pathology, Navodaya Dental College, Raichur, Karnataka, India

Date of Web Publication17-Nov-2015

Correspondence Address:
Dr. Santosh Hunasgi
Department of Oral and Maxillofacial Pathology, Navodaya Dental College, Raichur - 584 103, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-8844.169783

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  Abstract 

Oral surgical procedures mainly tooth extraction can be related with an extended hemorrhage owed to the nature of the process resulting in an "open wound." The attempt of this paper is to present a case of massive postoperative clot formation after tooth extraction and highlight on the oral complications of surgical procedures. A 32-year-old male patient reported to the Dental Clinic for evaluation and extraction of grossly decayed 46. Clinical evaluation of 46 revealed root stumps. Extraction of the root stumps was performed, and it was uneventful. Hemostasis was achieved and postsurgical instructions were specified to the patient. The patient reported to the clinic, the very subsequent morning with a criticism of bleeding at the extraction site. On clinical examination, bleeding was noted from the socket in relation to 46. To control bleeding, oral hemostatic drugs Revici - E (Ethamsylate 500 mg) was prescribed and bleeding was stopped in 2 h. However, a massive clot was formed at the extraction site. Further, this clot resolved on its own in 1-week time. Despite the fact that dental extraction is considered to be a minor surgical procedure, some cases may present with life-threatening complications including hemorrhage. Vigilant and significant history taking, physical and dental examinations prior to dental procedures are a must to avoid intraoperative and postoperative complications.

Keywords: Complication, extraction, hemorrhage, hemostatic drug


How to cite this article:
Hunasgi S, Koneru A, Manvikar V, Vanishree M, Surekha R. Massive clot formation after tooth extraction. J Orofac Sci 2015;7:132-5

How to cite this URL:
Hunasgi S, Koneru A, Manvikar V, Vanishree M, Surekha R. Massive clot formation after tooth extraction. J Orofac Sci [serial online] 2015 [cited 2019 Jul 19];7:132-5. Available from: http://www.jofs.in/text.asp?2015/7/2/132/169783


  Introduction Top


Postoperative problems may also be common or specific to the category of surgery undergone. Common general postoperative complications include postoperative fever, hemorrhage, wound infection, deep vein thrombosis, and embolism. [1]

The maximum occurrence of postoperative complications is between 1 and 3 days following the operation. On the other hand, precise complications occur in the subsequent distinct temporal patterns: Early postoperative, numerous days after the operation, during the postoperative phase, and in the delayed postoperative period. [1]

Immediate postoperative complications include primary hemorrhage-starting during surgery or subsequent postoperative amplification in blood pressure, shock-blood loss, acute myocardial infarction, pulmonary embolism or septicemia, and at last, low urine production-insufficient fluid substitute intraoperatively and postoperatively. [2]

Early postoperative problems include acute confusion-dehydration and sepsis, nausea and vomiting, fever, analgesia or anesthesia-related, secondary hemorrhage-frequently as a result of infection, and wound dehiscence. [1],[2]

Late postoperative complications include constant sinus tract formation, reappearance of lesions that are treated by surgery example: Keloid formation, cosmetic appearance, and malignancy depend on numerous factors. [3]

Oral surgical procedures mainly tooth extraction can be connected with an extended hemorrhage owed to the nature of the practice ensuing in an "open wound." [4] The attempt of this case report is to present a case of massive postoperative clot formation after tooth extraction and highlight on the oral complications of surgical procedures.


  Case Report Top


A 32-year-old male patient reported to the Dental Clinic for evaluation and extraction of grossly decayed 46. Clinical evaluation of 46 revealed root stumps. Scaling was performed at the initial appointment. Thereafter, extraction of 46 root stumps was planned. There was no history of any past or present noteworthy illness such as coagulation disorders, liver disorders, and prolonged hospitalization or medications.

Surgical procedure

The dentist planned to extract the tooth under LA. An injection of 2% Lignocaine with 1:80,000 adrenaline was administered. Extraction of the root stumps was performed, and it was uneventful. Hemostasis was attained, and postsurgical directions were specified to the patient. Directions incorporated a caution not to influence the surgical place or effort to retract the lip to visualize the surgical region. Antibiotics and analgesics were prescribed, and the patient was recalled for follow-up after 2 days.

Postoperative sequela

The patient reported to the clinic, the very subsequent morning with a complaint of bleeding at the extraction site. Feedback from the patient revealed that the patient did not follow the postextraction instructions of keeping the gauze piece for more than half an hour. Later when he took out the gauze piece; he observed bleeding from the extraction site. Further, the patient himself placed a gauze piece to stop the bleeding. On clinical examination, bleeding was noted from the socket in relation to 46. The place was irrigated with povidone-iodine solution, and gauze was kept for half an hour for observation. Bleeding was still present after half an hour. Therefore, hematological tests were completed, and all the values were established to be within normal limits. To control bleeding, oral hemostatic drug Revici - E (Ethamsylate 500 mg) was prescribed and bleeding was stopped in 2 h. However, a massive clot was formed at the extraction site in sometime later [Figure 1]. Further, this clot resolved on its own in 1-weeks' time [Figure 2].
Figure 1: Massive clot formation at the surgical site


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Figure 2: Massive clot resolved at the surgical site


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  Discussion Top


The life-threatening intraoperative or postoperative hemorrhage is one of the few complications of extraction. Hemorrhage in its simple terms refers to the getaway of blood from blood vessels. [5]

Depending on the moment of incidence, hemorrhage can be segregated as primary, intermediate or secondary. Primary hemorrhage takes place throughout the time of surgery and is ascribed to the wounding of the blood vessels. Intermediate hemorrhage refers to bleeding that happens inside 24 h of surgery. The possibility of this may possibly be recognized to many factors such as removal of pressure, dissipation of vasoconstrictive agents, and reduction of blood vessels. Secondary hemorrhage occurs after 24 h of surgery and is normally ascribed to many factors such as infection, intrinsic trauma, occurrence of foreign bodies such as fragment of bone, a speck of enamel, or a portion of dental restorative dressing substance that could cause repetitive, and delayed union of blood coagulum. [6],[7]

In this article, we report a case where after the extraction of lower right first molar, a massive clot was seen.

During the postoperative period of extraction of a tooth, patients frequently present with swelling, pain, trismus, hemorrhage, and poor mastication function. [6]

Postoperative hemorrhage seen after extraction of a tooth can be related to several reasons. First, the tissues of mouth and jaw are extremely vascular. Subsequently, the extraction of a tooth leaves an open wound and by means of both soft tissue and the bone open; which permits added bleeding during surgery. Third, patients may be inclined to play with the region of surgery with their tongue and infrequently dislodge the blood clot, which begins secondary bleeding. The tongue may as well cause secondary bleeding by generating small negative pressures that cause suction of the blood clot from the region. Finally, salivary enzymes could lyse the blood clot before it gets organized and disturbing the formation of granulation tissue. [6],[8] The present patient revealed that he did not follow the postextraction instructions of keeping the gauze piece not more than half an hour. Thus, massive postsurgical hemorrhage was seen in this patient.

While a patient presents with a noteworthy postsurgical hemorrhagic sequel such as the present patient, laboratory blood studies are supportive in determining precise risks or contraindications to persistent dental procedures such as impactions. However, the laboratory findings in the present case were also within the normal limits.

The hemorrhage that is seen after the tooth extraction is typically due to venous hemorrhage. Therefore, the patient may encompass difficulty controlling the bleeding with force if the hemorrhage is seen even after half an hour. During that time if patient calls from home, advise them to wipe away the clot with a piece of gauze and apply force for 10 min. Otherwise, if the patient is in the office, inject bleeding sites with 1/50,000 epinephrine, curette the discharge of fibrin clot away and suture the area or if bleeding persists, vasoconstrictive substances such as thrombin or collagen (procoagulants) may be employed. However, active bleeding which cannot be controlled by local measures in the dental office should be referred to the nearest hospital so that the airway can be secured, and the hemorrhage is managed appropriately. [9]

To control the hemorrhagic risk in patients after intraoral surgical procedures, several protocols have been proposed in literature. Some authors have recommended a combination of local antifibrinolytic therapy and hemostatic agents for the prevention of postoperative bleeding. Other authors have suggested patients can safely use tranexamic acid as an antifibrinolytic local agent for 2 days after the surgery. While other investigators have proposed the sole use of fibrin glue to prevent the hemorrhagic complications; however, these fibrin products are expensive and raise the question of the potential for infectious contaminations. [10] However, in this case to control the bleeding, oral hemostatic drug such as Revici - E (Ethamsylate 500 mg) was prescribed and bleeding was stopped in 2 h.

The normal clotting mechanism is as a cascade of events where the mechanism is such that one factor will activate the following factor in a sequenced reaction resulting in the formation of clot. [4] In this case, the above-mentioned many factors would have hampered blood clotting. However, when Revici - E was given, bleeding was stopped but a large massive dark red clot that is rich in hemoglobin derived from erythrocytes was seen. Clots are generally removed by either high-speed suction or a large curette. Following removal of the clot, saline irrigation, and direct pressure can be applied to the exposed area. Thrombolytic drugs such as tissue plasminogen activator and streptokinase can also be used to dissolve blood clots. [4]

Healing of extraction site takes place after the clot formation and later there will be a progression of that clot to a reorganized matrix preceding to the formation of new bone. [4] Thus, sometimes the clot may resolve on its own, such as in this case.


  Conclusion Top


Despite the fact that dental extraction is considered to be a minor surgical procedure, some cases may present with life-threatening complications including hemorrhage. Vigilant and significant history taking, physical and dental examinations prior to dental procedures are a must to avoid intraoperative and postoperative complications. Therefore, Dental Surgeon plays a crucial role in diagnosing and managing these postextraction hemorrhages. Thus, this present case report of massive clot seen after a simple extraction is added to literature so that dentist should be familiar with the incidence of postextraction complications and their management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Thompson JS, Baxter BT, Allison JG, Johnson FE, Lee KK, Park WY. Temporal patterns of postoperative complications. Arch Surg 2003;138:596-602.  Back to cited text no. 1
    
2.
Association of Anaesthetists of Great Britain and Ireland, Thomas D, Wee M, Clyburn P, Walker I, Brohi K, et al. Blood transfusion and the anaesthetist: Management of massive haemorrhage. Anaesthesia 2010;65:1153-61.  Back to cited text no. 2
    
3.
Guo S, Dipietro LA. Factors affecting wound healing. J Dent Res 2010;89:219-29.  Back to cited text no. 3
    
4.
Druckman RF, Fowler EB, Breault LG. Post-surgical hemorrhage: Formation of a "liver clot" secondary to periodontal plastic surgery. J Contemp Dent Pract 2001;2:62-71.  Back to cited text no. 4
    
5.
Kruger GO, editor. Hemorrhage and shock"; Alling CC III, Alling RD. Textbook of Oral and Maxillofacial Surgery. 6 th ed., Vol. 229, Ch. 12. St. Louis: The C.V. Mosby Company; 1984. p. 236-9.  Back to cited text no. 5
    
6.
Lapeyrolerie F. Management of dentoalveolar hemorrhage. Dent Clin North Am 1973;17:523-32.  Back to cited text no. 6
    
7.
Pandya D, Manohar B, Mathur LK, Shankarapillai R. "Liver clot": A rare periodontal postsurgical complication. Indian J Dent Res 2012;23:419-22.  Back to cited text no. 7
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8.
Hupp JR, Peterson LJ. Principles of surgery, Prevention and management of surgical complications. In: Pertson LJ, editor. Contemporary Oral and Maxillofacial Surgery. 3 rd ed., Ch. 3, 11. St. Louis: C.V. Mosby Company; 1998. p. 48-9, 270-3.  Back to cited text no. 8
    
9.
Nath D, Kumath M, Tandon S, Panwar M. Fatal Hemorrhage following extraction of first molar. J Indian Acad Forensic Med 2011;33:370-1.  Back to cited text no. 9
    
10.
Eldibany RM. Platelet rich fibrin versus Hemcon dental dressing following dental extraction in patients under anticoagulant therapy. Tanta Dent J 2014;11:75-84.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2]



 

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