The Bleeding That Won't Stop After a Simple Extraction
A 68-year-old woman undergoes extraction of tooth 36 under local anesthesia. The procedure is uncomplicated, but 40 minutes after placement of a gauze pack she continues to ooze bright red blood from the socket. She reports that she takes warfarin for atrial fibrillation and that her INR was checked last week. She also takes aspirin 81 mg daily and a fish oil supplement. Her blood pressure today is 158/94 mmHg. She is anxious and has a history of easy bruising. She has no known bleeding disorder and no liver disease. The socket appears to have a small soft tissue tear at the lingual margin.
1. List the differential causes of continued bleeding and explain how you would prioritize them.
Read the worked answer
The differential includes local factors and systemic factors. Local: soft tissue tear at the lingual margin, inadequate pressure, dislodged clot, or a small vessel injury. Systemic: anticoagulation with warfarin (INR unknown today), antiplatelet effect of aspirin, fish oil's mild antiplatelet effect, and elevated blood pressure that promotes bleeding. Prioritize local causes first because they are common and correctable: inspect for a tear, ensure adequate pressure with gauze, and consider suturing the tear. Then assess systemic factors: obtain a current INR rather than relying on last week's value, and check whether the INR is in the therapeutic range. Elevated blood pressure is a modifiable contributor and should be addressed. The judgment is to treat the most likely and most correctable cause first while gathering information, not to assume a bleeding disorder.
2. Should you stop her warfarin or aspirin before future extractions? Justify your answer.
Read the worked answer
No. For most dental extractions, warfarin should not be stopped if the INR is within the therapeutic range, typically 2.0–3.0 for atrial fibrillation. Stopping anticoagulation exposes her to thromboembolic risk-stroke-which outweighs the usually manageable bleeding risk from a dental extraction. Aspirin for secondary prevention should also generally be continued; stopping it can increase cardiovascular risk. The correct approach is to check the INR shortly before the procedure, coordinate with her physician if the INR is supratherapeutic, and use local hemostatic measures: atraumatic technique, suturing, pressure, and topical hemostatic agents if needed. Fish oil is a mild antiplatelet and is not a reason to stop. Document the coordination with her prescriber.
3. Outline your immediate management of the bleeding socket and the criteria for escalation.
Read the worked answer
Immediate management: reassure the patient, remove the old gauze, and inspect the socket and surrounding tissue. If there is a soft tissue tear, infiltrate local anesthetic and place a suture to approximate the margins. Apply firm pressure with gauze for at least 20–30 minutes and have the patient bite steadily. If bleeding persists, consider a topical hemostatic agent (e.g., oxidized cellulose or gelatin sponge) placed in the socket with sutures to retain it. Address blood pressure: advise rest and follow-up with her physician if elevated. Escalate if bleeding is profuse, continues despite local measures, or if she has signs of hypovolemia or an elevated INR. In that case, contact her physician or emergency services and consider reversal. Provide written post-operative instructions and a follow-up contact.