Despite the care and professional performance of oral-surgical procedures, postoperative bleeding cannot be completely avoided. Causes may be iatrogenic, congenital or medication-related. It most often occurs within the first 24 hours after the procedure, and less often later. In patients with blood-clotting disorders, longer and more frequent follow-up after the procedure is therefore advised. Even the smallest bleeding episodes that last longer than one day are not negligible, while larger ones that could pose an immediate threat to life are fortunately very rare.
Postoperative bleeding may occur in healthy patients, but much more often in those with congenital or acquired blood-clotting disorders or in those taking medicines that alter blood clotting. A detailed medical history before procedures, in which patients should state the medicines they are taking, previous clotting problems after dental procedures, clotting problems after injuries and similar information, is therefore crucial for avoiding such complications. Consultation with an internist, general practitioner, oncologist… is a wise step, given that many patients themselves do not even know which medicines they are taking or which systemic diseases they have.
Congenital blood-clotting disorders include haemophilia A, B and C and Von Willebrand-Jürgens syndrome. In haemophilia, blood-clotting factors (VIII, IX and XI) are missing. It is inherited recessively via the X chromosome, so heterozygous women are carriers. It occurs in seven patients per 100,000 people. In 80% of cases patients have haemophilia A (factor VIII is missing). Haemophilia B (factor IX is missing) is present in 13%, and haemophilia C (factor XI is missing) in 7%. The disease has different levels of severity. Subhaemophilia is present in 15 to 60%, a mild form in 6 to 15%, a moderate form in 1 to 5%, and a severe form in less than 1%. In all forms of haemophilia, the procedure must be coordinated in advance with an internist, who will prepare the patient appropriately according to the severity of the disease. In severe forms of the disease, hospitalisation and an oral-surgical procedure in hospital are necessary. If a patient with haemophilia is treated on an outpatient basis, tight closure of the wound with absorbable suture material and administration of appropriate medicines are required, preferably by an internist. Antibiotics are recommended in order to avoid infection of the haematoma.
Von Willebrand-Jürgens syndrome, with a prevalence of around 1%, is the most common congenital blood-clotting disorder. The clinical picture is characterised by impaired adhesive ability of platelets, caused by a disorder of the vascular endothelium and a disorder of Von Willebrand factor, which is produced in megakaryocytes. We distinguish type 1 (factor deficiency), type 2 (impaired factor function) and type 3 (complete absence of the factor). Type 2 disease is the most common (60 to 80%) and is characterised by superficial haematomas, prolonged bleeding after minor injuries, heavy menstruation, spontaneous nosebleeds and characteristic delayed bleeding after tooth extraction. It is precisely this disease that is most often first diagnosed by a dentist at the first tooth extraction. If the patient already reports this disease in the medical history, consultation with an internist during preparation for the procedure is crucial. In milder forms, medication preparation for the oral-surgical procedure is sufficient; in more severe forms, as with haemophilia, hospitalisation for the procedure is mandatory.
Liver cirrhosis and leukaemia are conditions that deserve attention when deciding on an oral-surgical procedure. In addition to other problems, both diseases also share a common denominator that causes clotting disorders. A general medical history before the procedure and consultation with an internist for a more precise definition of the disease again prove to be a wise and indispensable decision.
Medicines that affect blood clotting are intended to prevent the formation of venous blood clots. This group includes glycoprotein IIb/IIIa receptor antagonists, thrombin inhibitors, heparin, vitamin K antagonists, ADP antagonists, platelet aggregation inhibitors… Most of these medicines are taken by patients after they have already experienced medical complications, while aspirin is the most commonly used prophylactic medicine belonging to the group that blocks platelet aggregation (antiplatelet agents). The effect of acetylsalicylic acid on platelet function is irreversible, so the effect on prolonged blood clotting depends on the lifespan of a platelet (7 to 10 days), which is also the reason for determining the time delay of the procedure after stopping Aspirin (1 week). Healthy bone marrow can, however, replace the weakened platelet function by 30–50% within two to three days. The likelihood of postoperative complications in the form of bleeding is therefore relatively low when taking a prophylactic dose (100 mg), although patients must be informed about the greater possibility of haematoma formation. Patients therefore do not need to discontinue prophylactic Aspirin therapy for routine oral-surgical procedures. If patients are taking higher daily doses of acetylsalicylic acid, preoperative preparation including consultation with an internist is required. If the dose can be reduced to 100 mg without adverse effects, the procedure can also be performed. In this case, delaying the procedure for one week is necessary. Vitamin K antagonists affect the enzyme vitamin K epoxide reductase and thus the metabolism of the vitamin, which is required for the synthesis of various blood-clotting factors. Thromboplastin time was used as a measure of the effect of the medicine on clotting and, within normal clotting function, may vary from 70 to 120%. Because of individual variations, the values are standardised and given as INR (International Normalized Ratio). Patients taking such medicines always have a document on which INR values are recorded. According to the professional literature, simpler procedures should be performed at maximum INR values of 2.0 to 3.0. Simpler procedures include those for which we believe that stopping bleeding by suturing (tight closure of the wound) will not present a problem. For more difficult procedures (serial extractions, professional tooth cleaning…), the INR value needs to be reduced below 2.0. For all such procedures, prior consultation with an internist is required; the internist can determine the risks of reducing the therapeutic dose and, if necessary, prescribe temporary heparin therapy. Medicines for which the therapeutic effect cannot be measured using INR values therefore require particular attention and consultation with an internist (NOACs: Pradaxa, Apixaban, Rivaroxaban). Patients taking medicines (ADP antagonists: Plavix, Iscover, Efient,…) after stent placement or insertion of coronary endoprostheses usually must not discontinue or change therapy during the first six to twelve months after the procedure. They most often receive a double or even triple combination of anticoagulant medicines. Only truly urgent oral-surgical conditions may be an indication for a procedure, provided there is interdisciplinary management by an internist and dentist. Despite what has been written, practice has shown that simple tooth extractions with subsequent suturing of the wound do not present a possibility of bleeding after the procedure.
Among the common reasons for bleeding, extensive tissue injury during surgical procedures should be mentioned. Extensive bleeding during and after procedures occurs with injury to larger vessels, which as a rule accompany larger nerves of the same name. Unexpected patient reactions can lead to soft-tissue injuries from rotary instruments. Injuries to the floor of the mouth and the sublingual artery (a. sublingualis) are particularly dangerous; in very atrophic jaws this vessel lies on or even within the lingual cortical plate of the mandible.
Postoperative bleeding may occur in healthy patients, but much more often in those with congenital or acquired blood-clotting disorders or in those taking medicines that alter blood clotting. A detailed medical history before procedures, in which patients should state the medicines they are taking, previous clotting problems after dental procedures, clotting problems after injuries and similar information, is therefore crucial for avoiding such complications. Consultation with an internist, general practitioner, oncologist… is a wise step, given that many patients themselves do not even know which medicines they are taking or which systemic diseases they have.
Congenital blood-clotting disorders include haemophilia A, B and C and Von Willebrand-Jürgens syndrome. In haemophilia, blood-clotting factors (VIII, IX and XI) are missing. It is inherited recessively via the X chromosome, so heterozygous women are carriers. It occurs in seven patients per 100,000 people. In 80% of cases patients have haemophilia A (factor VIII is missing). Haemophilia B (factor IX is missing) is present in 13%, and haemophilia C (factor XI is missing) in 7%. The disease has different levels of severity. Subhaemophilia is present in 15 to 60%, a mild form in 6 to 15%, a moderate form in 1 to 5%, and a severe form in less than 1%. In all forms of haemophilia, the procedure must be coordinated in advance with an internist, who will prepare the patient appropriately according to the severity of the disease. In severe forms of the disease, hospitalisation and an oral-surgical procedure in hospital are necessary. If a patient with haemophilia is treated on an outpatient basis, tight closure of the wound with absorbable suture material and administration of appropriate medicines are required, preferably by an internist. Antibiotics are recommended in order to avoid infection of the haematoma.
Von Willebrand-Jürgens syndrome, with a prevalence of around 1%, is the most common congenital blood-clotting disorder. The clinical picture is characterised by impaired adhesive ability of platelets, caused by a disorder of the vascular endothelium and a disorder of Von Willebrand factor, which is produced in megakaryocytes. We distinguish type 1 (factor deficiency), type 2 (impaired factor function) and type 3 (complete absence of the factor). Type 2 disease is the most common (60 to 80%) and is characterised by superficial haematomas, prolonged bleeding after minor injuries, heavy menstruation, spontaneous nosebleeds and characteristic delayed bleeding after tooth extraction. It is precisely this disease that is most often first diagnosed by a dentist at the first tooth extraction. If the patient already reports this disease in the medical history, consultation with an internist during preparation for the procedure is crucial. In milder forms, medication preparation for the oral-surgical procedure is sufficient; in more severe forms, as with haemophilia, hospitalisation for the procedure is mandatory.
Liver cirrhosis and leukaemia are conditions that deserve attention when deciding on an oral-surgical procedure. In addition to other problems, both diseases also share a common denominator that causes clotting disorders. A general medical history before the procedure and consultation with an internist for a more precise definition of the disease again prove to be a wise and indispensable decision.
Medicines that affect blood clotting are intended to prevent the formation of venous blood clots. This group includes glycoprotein IIb/IIIa receptor antagonists, thrombin inhibitors, heparin, vitamin K antagonists, ADP antagonists, platelet aggregation inhibitors… Most of these medicines are taken by patients after they have already experienced medical complications, while aspirin is the most commonly used prophylactic medicine belonging to the group that blocks platelet aggregation (antiplatelet agents). The effect of acetylsalicylic acid on platelet function is irreversible, so the effect on prolonged blood clotting depends on the lifespan of a platelet (7 to 10 days), which is also the reason for determining the time delay of the procedure after stopping Aspirin (1 week). Healthy bone marrow can, however, replace the weakened platelet function by 30–50% within two to three days. The likelihood of postoperative complications in the form of bleeding is therefore relatively low when taking a prophylactic dose (100 mg), although patients must be informed about the greater possibility of haematoma formation. Patients therefore do not need to discontinue prophylactic Aspirin therapy for routine oral-surgical procedures. If patients are taking higher daily doses of acetylsalicylic acid, preoperative preparation including consultation with an internist is required. If the dose can be reduced to 100 mg without adverse effects, the procedure can also be performed. In this case, delaying the procedure for one week is necessary. Vitamin K antagonists affect the enzyme vitamin K epoxide reductase and thus the metabolism of the vitamin, which is required for the synthesis of various blood-clotting factors. Thromboplastin time was used as a measure of the effect of the medicine on clotting and, within normal clotting function, may vary from 70 to 120%. Because of individual variations, the values are standardised and given as INR (International Normalized Ratio). Patients taking such medicines always have a document on which INR values are recorded. According to the professional literature, simpler procedures should be performed at maximum INR values of 2.0 to 3.0. Simpler procedures include those for which we believe that stopping bleeding by suturing (tight closure of the wound) will not present a problem. For more difficult procedures (serial extractions, professional tooth cleaning…), the INR value needs to be reduced below 2.0. For all such procedures, prior consultation with an internist is required; the internist can determine the risks of reducing the therapeutic dose and, if necessary, prescribe temporary heparin therapy. Medicines for which the therapeutic effect cannot be measured using INR values therefore require particular attention and consultation with an internist (NOACs: Pradaxa, Apixaban, Rivaroxaban). Patients taking medicines (ADP antagonists: Plavix, Iscover, Efient,…) after stent placement or insertion of coronary endoprostheses usually must not discontinue or change therapy during the first six to twelve months after the procedure. They most often receive a double or even triple combination of anticoagulant medicines. Only truly urgent oral-surgical conditions may be an indication for a procedure, provided there is interdisciplinary management by an internist and dentist. Despite what has been written, practice has shown that simple tooth extractions with subsequent suturing of the wound do not present a possibility of bleeding after the procedure.
Among the common reasons for bleeding, extensive tissue injury during surgical procedures should be mentioned. Extensive bleeding during and after procedures occurs with injury to larger vessels, which as a rule accompany larger nerves of the same name. Unexpected patient reactions can lead to soft-tissue injuries from rotary instruments. Injuries to the floor of the mouth and the sublingual artery (a. sublingualis) are particularly dangerous; in very atrophic jaws this vessel lies on or even within the lingual cortical plate of the mandible.