Clin Oral Invest (2014) 18:16551661
DOI 10.1007/s00784-013-1133-x
ORIGINAL ARTICLE
Causes and timing of delayed bleeding after oral surgery
Cornelia Czembirek & Wolfgang Paul Poeschl & Christina Eder-Czembirek &
Michael Bernhard Fischer & Christos Perisanidis & Philip Jesch & Kurt Schicho &
Angel Dong & Rudolf Seemann
Received: 27 April 2013 / Accepted: 31 October 2013 / Published online: 28 November 2013
# Springer-Verlag Berlin Heidelberg 2013
Abstract
Objectives This study examines a cohort of patients who
suffered bleeding requiring hemostatic intervention after oral
surgery. The reasons for bleeding and the interval between
surgery and onset of bleeding are investigated.
Materials and methods Between 1998 and 2009, 1,819 cases
were eligible for this retrospective study. Factors (independent
parameters) influencing the interval (dependent variable) were
analyzed using negative binomial count regression models
(NegBin II). The significance of each regressors effect was
tested using Walds test and the total effect using likelihood
ratio test.
Results Of the patients examined, 1,101 (60.1 %) did not take
anticoagulants, 394 (21.5 %) took phenprocoumon, 233
(12.7 %) took acetylsalicylic acid, 33 (1.8 %) took
clopidogrel, 17 (0.9 %) took more than one anticoagulant,
and 78 (4.3 %) had a congenital blood disorder. After simple
tooth extraction, 95.3 % suffered bleeding; 69.7 % of extrac-
tions were performed in the molar region. Later that day of
surgery, 66.0 % of all patients showed bleeding. The bleeding
interval was significantly prolonged by anticoagulant therapy
with phenprocoumon, by congenital clotting disorders.
C. Czembirek (*) : W. P. Poeschl : C. Eder-Czembirek :
C. Perisanidis : K. Schicho : A. Dong : R. Seemann
University Clinic of Cranio-, Maxillofacial and Oral Surgery,
Medical University of Vienna, Waehringer Guertel 18-20,
1090 Vienna, Austria
e-mail: cornelia.czembirek@meduniwien.ac.at
M. B. Fischer
University Clinic of Blood Serology and Transfusion Medicine,
Medical University of Vienna, Waehringer Guertel 18-20,
1090 Vienna, Austria
P. Jesch
Dental Ambulatory Wienerberg City, Hertha-Firnberg-Strasse 10 / 2 /
1, 1110 Vienna, Austria
Conclusions Normal tooth extractions are underestimated for
their risk for postoperative bleeding, especially in the molar
region. Anticoagulant therapy or congenital blood disorders
present oral surgeons with a further challenge.
Clinical relevance Performing surgery before midday allows
surgeons managing postoperative bleeding themselves for a
better patient satisfaction. Intensified information about cor-
rect postoperative behavior is crucial. Prolonged blood coag-
ulation should intensify follow-up checks. Patients with con-
genital blood disorders and patients at high risk for bleeding
with the need for substitution of platelets or clotting factors
should receive inpatient care. More potent, local applicable
coagulant agents are required for these patients.
Keywords Bleeding . INR . Anticoagulant therapy . Blood
disorder . Oral surgery
Introduction
Bleeding is one of the possible complications occurring either
immediately during an oral surgery (primary bleeding) or hours
or days after the intervention (secondary bleeding). This study
concerns conventional extractions as well as advanced
dentoalveolar interventions such as root-end resection or
wisdom tooth removal. The probability of bleeding after surgery
is increased in the case of wound inflammation [1, 2], congenital
clotting disorder, hypertension, and antithrombotic therapy [3].
Several intraoperative procedures have been established to
control bleeding and to prevent further possible bleeding. The
simplest method is wound compression. In primary bleeding,
this is the main option used to gain time to prepare for further
hemostatic measures. In secondary bleeding, wound compres-
sion is the first choice for hemostasis and is achieved by the
patient biting on gauze (mechanical modality). Wound com-
pression is analogous to wound adaption with sutures, or
1656
obturation of spongious bone with bony wax (B. Braun
Melsungen AG, Melsungen, Germany). Other hemostatic
methods require additional equipment. Thermal modalities
include coagulation with diathermy or laser. Biochemical
means include human fibrinogen, human thrombin, and the
application of hemostatic agents such as Tabotamp
(Ethicon Biosurgery, Johnson & Johnson MEDICAL
GmbH, Norderstedt, Germany), an oxidized regenerated cel-
lulose that also exerts bactericidal effects [4]; Spongostan, a
gelatine sponge of porcine origin; fibrin glue; TachoSil
(Nycomed International Management GmbH, Zurich, Swit-
zerland), an equine-derived, honeycomb-like collagen coated
with a dry layer of coagulation factors [5]; and tranexamic
acid (Cyklokapron, MEDA Pharma GmbH, Wangen-
Brttisellen, Switzerland), a synthetic derivative of the amino
acid lysine and an antifibrinolytic drug [6].
To stop secondary bleeding, the same intraoperative treat-
ment modalities can be utilized.
The mechanisms of bleeding have to be distinguished
between primary and secondary bleeding. Primary bleeding
occurs due to direct trauma caused by a surgical instrument or
the rupture of tissue, such as when periodontal fibers are torn
apart during tooth extraction or during blunt scissor prepara-
tion. A secondary bleeding can result from the ease of the
initial vascular spasm due to epinephrine added to the local
anesthesia, or by injury to the soft and fragile blood clot.
Numerous other reasons of secondary bleeding are also pos-
sible, including external heat, rising blood pressure, adaption
of coagulation therapy, and hyperemia of the inflamed wound.
This retrospective study examines a 12-year cohort of
patients, between 1998 and 2009, who suffered from postop-
erative bleeding requiring hemostatic intervention. The aims
of the study were (a) to point out the reasons for postoperative
bleeding, (b) to examine the time interval between surgery and
onset of bleeding, and (c) to give recommendations for the
best time for operative interventions and to identify patients at
risk of further inpatient treatment.
Materials and methods
The University Hospital for Cranio-, Maxillofacial and Oral
Surgery sees a substantial proportion of patients with delayed
hemorrhage after oral surgery. This is to the greatest possible
extent because the University Hospital for Cranio-, Maxillofa-
cial and Oral Surgery is the only faculty available in eastern
Austria to treat patients after 1 a.m. Consequently, the University
Hospital for Cranio-, Maxillofacial and Oral Surgery has access
to a rich database of patients for a retrospective study of post-
operative bleeding. The present study includes patients since the
implementation of the clinics digital documentation system in
1998 (Clinicware, Version 336.026, GWI AG, Trier, Germany).
The study included patients who presented with delayed
Clin Oral Invest (2014) 18:16551661
postoperative bleeding between 1998 and 2009. Most of the
patients had been treated in dental offices during the day and
presented with delayed bleeding during nighttime. Since these
patients registered in our clinic due to secondary bleeding, a
common clinical standard had not been applied. Some of these
patients might have had primary wound closure but most of
themespecially due to the fact that the majority had been
extractions onlyhad none. A total of 4,946 patients were
reviewed for sex, age, location of bleeding, the presence of
anticoagulation or congenital blood disorders, the underlying
surgical intervention, inpatient or outpatient, the date of sur-
gery, and the date when bleeding was registered. Drugs other
than anticoagulants were not evaluated. Only patients who
originally underwent planned oral surgical interventions were
included. Patients with oral pathologies as sources of bleeding,
such as periodontitis, trauma, or tumors were excluded, as well
as patients with acute interventions (abscess incision). Cases
with missing or flawed documentation were also excluded.
This study protocol was sent to and approved by the Ethical
Committee of the Medical University Vienna (EK# 371/2010).
Of the 4,946 cases with postoperative bleeding complica-
tions, 3,113 were excluded: 1,098 with abscess incision, 566
with dentoalveolar bleeding due to trauma, 112 with bleeding
due to periodontitis, 88 with bleeding from tumor erosion, 308
with an unspecified surgical procedure, 697 due to missing or
invalid date of surgery, and 244 without documented surgical
treatments. Data of the 1,833 eligible patients were
reformatted into a Microsoft Excel spreadsheet.
Data analysis
Data was analyzed with statistical methods using the open source
statistical software package R (Version 2.15.1, The R Foun-
dation for Statistical Computing, http://www.r-project.org).
Possible factors (independent parameters) influencing the
time interval until the onset of bleeding (dependent variable)
were analyzed. Since the bleeding interval is not normally
distributed but rather count data (starts with zero, never neg-
ative, and always an integer), a Poisson distribution or even
better a negative binomial (NegBin) distribution may be ap-
plied. The interval was estimated using negative binomial
count regression models (NegBin II) since the variance of
bleeding time was greater than the mean (i.e., overdispersed).
Univariate NegBin II models were compared to the null by
means of likelihood ratio testing. Finally, the full multivariate
NegBin II model was computed and compared to individual
models from likelihood ratio tests. The significance of each
regressors estimate was calculated using Walds test and the
total effect using likelihood ratio testing. In case of nominal
factors (such as localization), dummy variables are introduced
whereby four regions (incisor, canine, premolar, molar) are
modelled by three dummy variables: canine, premolar, and
Clin Oral Invest (2014) 18:16551661
molar. The model then reports the bleeding interval of incisors
as constant value and the differences of canine/premolar/mo-
lar region as estimate of the dummy variable.
Results
Out of the 4,946 patients with postoperative bleeding, 1,833
patients were eligible according to the inclusion and exclusion
criteria. An overall bleeding interval (period between date of
surgery and date of presentation for postoperative bleeding) of
1.4 days and a variance of 12.1 was observed ranging from 0
to 37 days. A total of 64.97 % of all patients showed delayed
bleeding on the day of surgery, 20.96 % in the first 3 days
following surgery, and 9.18 % between the fourth and the
seventh day after surgery.
Anticoagulants Of the 1,833 cases, 1,101 (60.1 %) had no
history of anticoagulants. Of the remaining 732 patients, 394
(21.5 %, bleeding interval=23.7) had taken phenprocoumon,
233 (12.7 %, bleeding interval=1.33) had taken acetylsalicylic
acid, 33 (1.8 %, bleeding interval= 0.8 1.7) had taken
clopidogrel, 17 (0.9 %, bleeding interval=1.32.1) had more
than one type of anticoagulant, and 78 (4.3 %, bleeding inter-
val=23.3) had congenital blood disorders. Bleeding intervals
of patients under phenprocoumon and acetylsalicylic acid are
given in Fig. 1. All 1,833 patients contributed to the
anticoagulation NegBin II model regressing bleeding interval
Fig. 1 Boxplot of the bleeding
10
interval comparing
phenprocoumon and
acetylsalicylic acid
8
Days after surgical intervention
4 2
0 6
1657
on anticoagulant. No anticoagulation was used as the refer-
ence group. The comparison of anticoagulation and congenital
blood disorders to no anticoagulation showed a significant
difference in the time between intervention and onset of the
bleeding (likelihood ratio test for maximum likelihood estima-
tion (MLE) method: p LRT =0.00017), whereby phenprocoumon
and congenital disorders showed a similar significant effect of
1.80 (e0.589, p Walds test <104) and 1.84 (e0.608, p Walds test =0.024)
longer mean time, respectively. The effect of acetylsalicylic acid
was smaller and shown to be insignificant (e0.167 =1.18,
p Walds test =0.338). Patients on clopidogrel started bleeding ear-
lier than the reference group (e0.709 =0.492, p Walds test =0.199),
but the difference was also statistically insignificant. Similarly,
there was an insignificant difference between patients on multi-
ple anticoagulants and the reference group (e0.445 =1.56,
p Walds test =0.550).
Surgery Of the 1,833 patients, 1,746 (95.3 %, bleeding inter-
val=1.33.5; range 037) suffered bleeding after tooth ex-
tractions, 29 patients suffered bleeding (1.6 %, bleeding inter-
val=0.41.0; range 05) after failed extractions, 34 patients
(1.9 %, bleeding interval=2.43.2; range 012) after dental
implantation, 13 patients (0.7 %, bleeding interval=2.95 ;
range 015) following cystectomies or root-end resections,
and 11 patients (0.6 %, bleeding interval=11.2; range 03)
after other dental treatments. The type of surgery did not
significantly influence the bleeding interval in the NegBin II
model (likelihood ratio test for MLE method: p LRT =0.054).
aspirine phenprocoumon
Anticoagulation
1658
The postoperative bleeding interval from tooth extractions
was used as the reference group. The postoperative bleeding
interval in cystectomies was longer than tooth extractions, but
this difference was found to be insignificant (factor=e0.777 =
2.18, p Walds test =0.224). Bleeding interval after dental implan-
tation was also insignificantly different from tooth extractions
(factor=e0.597 =1.82, p Walds test =0.135), as was dental proce-
dures (preparation) when compared to tooth extractions
(e0.295 =0.74, p Walds test =0.688). In contrast, failed extraction
showed a significantly smaller bleeding interval when com-
pared to successful tooth extractions (factor=e1.178 =0.31,
p Walds test =0.020).
Sex Of the 1,833 patients, 1,078 patients were male (58.8 %,
age 48.620.7, ranging from 2.7 to 97.8 years) and 755 were
female (41.2 %, age 50.522.0, ranging from 0.2 to 98.0 years).
A mean bleeding interval of 1.33.4 (range 037) was ob-
served in female patients and 1.43.5 (ranging from 0 to 26) in
male patients. The univariate NegBin II model analysis of
cohort sex did not show significant differences in bleeding
intervals between males and females (likelihood ratio test for
MLE method: p LRT =0.265; e0.127 =1.14, p Walds test =0.264).
Age The bleeding interval insignificantly lengthened by a factor
of 1.004 for every yearly increase in age (=e0.004, p Walds test =
0.124, p LRT =0.128).
Clinic Inpatients and outpatients showed a mean bleeding
interval of 0.10.8 (ranging from 0 to 8 days) and 1.43.6
(ranging from 0 to 37), respectively. This difference between
inpatients and outpatients was shown to be significant accord-
ing to the univariate NegBin II regression model (factor=
e2.39 =0.09, p Walds test <1012, likelihood ratio test for MLE
method: p LRT <1012).
Jaw Of the 1,833 patients, 763 had a valid specification of the
jaw and 618 had localization of teeth. Bleedings were almost
equally distributed to the maxilla (n =401, 52.6 %, bleeding
interval=1.94.6, range 037) and the mandible (n =362,
47.4 %, bleeding interval=1.53.4, range 033). In the
NegBin II regression model (likelihood ratio test for MLE
method: p LRT =0.159), bleeding in the maxilla started slightly
later than the mandible but the difference was found to be
insignificant (factor=e0.232 =1.26, p =0.158).
Localization In both maxilla and mandible localization, bleed-
ing was mainly registered in the molar region (maxilla 70.6 %,
bleeding interval 1.63.7, 031; mandible 69.3 %, bleeding
interval 1.64, 033). Only 7.4 % of bleedings occurred in the
maxillary incisor region (bleeding interval 0.81.4, 04),
9.2 % in the mandibular incisor region (bleeding interval 0.9
1.4, 06), 9.9 % affecting the maxillary canine (bleeding
interval 2.86.8, 036), 6.8 % affecting the mandibular canine
Clin Oral Invest (2014) 18:16551661
(bleeding interval 0.71.4, 05), 12.1 % affecting the maxil-
lary premolar region (bleeding interval 3.27.6, 037), and
14.7 % affecting the mandibular premolar region (bleeding
interval 1.93.4, 014) (Fig. 2). The localization was shown
to be insignificant in affecting bleeding interval (likelihood
ratio test for MLE method: p LRT =0.093). However, when
using maxillary incisors as reference group for comparison,
maxillary canines (factor=e1.245 =3.47, p Walds test =0.046) and
premolars (factor=e1.390 =4.01, p Walds test =0.021) showed sig-
nificantly longer bleeding intervals according to the univariate
NegBin II model. There were no significant differences in
other groups (maxillary molars 2.01-fold, p Walds test =0.171;
mandibular incisors 1.08-fold, p Walds test =0.913; mandibular
canines 0.88-fold, p Walds test =0.866; mandibular premolars
2.44-fold, p Walds test =0.135; mandibular molars 1.97-fold,
p Walds test =0.187).
All factors which were significant in the univariate statis-
tics (anticoagulation and clinic) were also significant in the
multivariate statistics (see Table 1).
Discussion
In countries of overaging population, the rising number of
patients treated with anticoagulants requires intensified col-
laboration between internists and dentists. Bleeding after an
oral (surgical) intervention is a common and unsettling com-
plication, about which every patient has to be informed before
treatment [7, 8]. Various factorsespecially anticoagulant
therapies such as phenprocoumon etc. and congenital blood
disordersincrease the risk of bleeding and especially de-
layed bleeding [9]. In this study, all patients with delayed
bleeding after projectable dental surgical interventions (i.e.,
with possibility of preoperative anticoagulant therapy adap-
tion) were included to provide further evidence of the time
interval between surgery and onset of bleeding. Cases of
spontaneous bleeding due to trauma, inflammation, or tumor
were excluded (in total, 19.9 % of the cohort with hemostatic
measures). As a possible source of bias, 65.5 % of the patients
with previous dental surgeries were included while the re-
maining 34.5 % had invalid documentation.
Bleeding interval Independent of any factor, bleeding oc-
curred on the same day of surgery in more than two thirds of
the cases. It can be assumed that the majority of postoperative
recurrent bleedings are persisting bleedings temporary sup-
pressed by adrenaline added to local anesthetics since most
bleeding complications occur within few hours after surgery.
Cause It is an underestimated fact that the main surgical
reason for a bleeding complication was a simple tooth extrac-
tion (95.3 %)not advanced dentoalveolar surgery. Typically,
Clin Oral Invest (2014) 18:16551661 1659

Fig. 2 Boxplot of the bleeding

10
interval comparing incisors,
canines, premolars, and molars

8
Days after surgical intervention
6
4
2
0

I C PM M
Localization

a conventional tooth extraction does not require soft tissue
wound closure, hence correct placement of the cotton swab
and adequate time of compression is crucial. Posterior teeth
with more than one andmoreovercontorted roots leave
large bony wounds, leading to more than two thirds of bleed-
ing complications in the molar region. Additionally,
compression in the molar region is more challenging for the
patient himself. Exposed bone surface has to be considered in
planning of the operative procedure.
Therapy with anticoagulants In this context, the anticoagulant
therapy plays an important role. Although two thirds of the

Table 1 Multivariate negative binomial count regression model

Factor Subfactor Estimate Std. error eestimate z value p Walds test p LRT

(Intercept) 0.17 0.46 1.19 0.38 0.707

Sex Male vs. female 0.03 0.18 1.03 0.15 0.884 0.885
Age 0.01 0.01 0.99 2.04 0.041 0.070
Anticoagulation/clotting disorder Phenprocoumon 0.96 0.26 2.61 3.71 0.0002 0.009
(ref. = no anticoagulation) Aspirin 0.14 0.26 1.15 0.54 0.590
Clopidogrel 0.25 0.59 0.78 0.42 0.672
Congenital 0.61 0.43 1.83 1.42 0.156
Surgery (ref. = extraction) Cystectomy 1.14 1.37 3.12 0.83 0.405 0.505
Dental procedure 0.34 1.44 0.71 0.24 0.814
Failed extraction 0.97 0.68 0.38 1.42 0.155
Implant 0.50 0.63 1.65 0.80 0.426
Jaw Maxilla vs. mandible 0.02 0.18 0.98 0.09 0.929 0.934
Localization (ref. = incisor) Canine 0.52 0.44 1.68 1.17 0.244 0.057
Molar 0.66 0.35 1.94 1.92 0.056
Premolar 1.09 0.40 2.97 2.71 0.007
Clinic Inpatient vs. outpatient 33.77 1.046106 0.00 0.00 0.999 <0.001

Estimates of the coefficients, standard errors, exponential of coefficient, and z value are given from left to right. Probability values of Walds test and
likelihood ratio test are given in the rightmost columns. Null deviance, 575.79 on 615 degrees of freedom; residual deviance, 445.64 on 600 degrees of
freedom; AIC, 1,795.1; theta, 0.2948; std. error, 0.0281; 2log-likelihood, 1,761.1060
1660 Clin Oral Invest (2014) 18:16551661

patients had no history of anticoagulants, the second largest Table 2 Interaction of chemotherapeutic agents and potency of
phenprocoumon
group was taking phenprocoumon with significant longer
surgery-to-bleeding intervals. Since the study period ended in Elevating the anticoagulant effect: Inhibiting the anticoagulant
2009, the new anticoagulants such as rivaroxaban (Xarelto) effect:
and dabigatran (Pradaxa) had not been considered in our
Allopurinol 6-Mercaptopurine
study. Experience with the bleeding risk of this drug group
Aminoglycoside Azathioprine
and recommendations on how to handle those before or during
Amiodarone Barbiturates
oral surgical interventions are under current investigation.
Anabolic steroids Carbamazepine
Hemostasis is a finely tuned orchestration of physical and
Cephalosporins Chlordiazepoxide
biochemical forces to arrest bleeding. The trauma induced by
Chinin Cholestyramine
tooth extraction leads to blood vessel injury and extravasation
of blood to the surrounding tissue. The endothelium lining of Chinidin Corticosteroids
vessels is physically denuded by injury, thereby gets activated Chinolone Diuretics
and generates a highly pro-thrombotic interface. Circulating Cimetidine Glutethimide
platelets bind and get activated on the injured site as a conse- Cisapride Griseofulvin
quence, while the coagulation pathway is triggered by the Clofibrate and other fibrates Nafcillin
exposure to tissue factor (TF). Subendothelial TF binds factor Chloramphenicol Phenytoin
VIIa, and the newly formed complex can convert factor X to Cloxacillin Rifampicin
Xa, which in turn assembles with cofactor Va and Ca2+ on the Co-trimoxazole Sucralfate
platelet phospholipid membrane to form a prothrombinase COX-2 inhibitors Trazodone
complex that cleaves prothrombin into active thrombin. Disulfiram Vitamin K
Thrombin production is sustained by an alternate tenase, the Erythromycin
complex of VIIIa and IXa, and further amplified through Fluconazole
positive feedback by thrombins activation of VIIIa and Va, Glucagon
as well as XIa required for factor IX activation. Finally, Isoniazid
thrombin cleaves fibrinogen and activates factor XIII to en- Macrolide
ables fibrin cross-linking. Cross-linked fibrin binds platelet Metronidazole
clusters, leading to hemostatic plug formation in the physical Miconazole
barrier to limit the blood loss after tooth extraction. Throm- Omeprazole
bins ability to activate inflammatory mediators and platelets Orlistat
capability to secrete pro-inflammatory and immune mediators Phenylbutazone
such as serotonin, platelet factor 4 (PF4), P-selectin, and Piroxicam
CD40L (CD154), as well as their ability to express toll like Propafenone
receptors (TLR) 4 and 9, suggest a bridge between their Propranolol
function in hemostasis and immunity. The results suggest that Salicylates
while the inhibition of platelets has a short-term effect on Statins
wound healing, the inhibition of clotting factors delays wound Sulfinpyrazone
healing with prolonged risk of postoperative bleeding. Sulfonamide
Since simple withdrawal of the anticoagulant therapy before Tamoxifen
oral surgery might induce a rebound effect and cause throm- Tetracycline
boembolic events in patients suffering from atherosclerosis Triazol derivatives
[10, 11], it is recommended that anticoagulant therapy is ad- Virustatics (saquinavir)
justed [12] but not stopped [11]. Several preoperative proto- Selective serotonin reuptake inhibitors
cols have been established to prevent postoperative bleeding: Immunosuppressant (leflunomide)
(1) adjusting the international normalized ratio (INR) to upper
limits of 3.0 [13, 14] when phenprocoumon is administered,
(2) changing to low molecular weight heparins, (3) pretreating It can be assumed that preoperative and operative manage-
with antibiotics in the case of inflammation, or (4) substituting ment is planned more carefully in patients with more than one
coagulation factors, when blood disorders are known. Previous anticoagulant drug as there are not even 0.9 % of registered
recommendations to discontinue phenprocoumon for smaller bleeding events. In addition, medication interactions have to be
surgical interventions have become obsolete in the light of the considered, leading to numbers of up to one fifth of bleeding
elevated risk of severe thromboembolic events, especially complications in patients treated with phenprocoumon.
when the target INR is 2.0 to 3.0 [15, 16]. Anticoagulation effects and thus bleeding susceptibility of
Clin Oral Invest (2014) 18:16551661
phenprocoumon are enhanced by different chemotherapeutic
agents (see Table 2). In consequence, Morimoto and colleagues
postulated that measuring of INR, when postoperative bleeding
occurred, is important [17]. Due to the fact that INR was not
routinely measured, it could not be included in this study. INR
was not analyzed, since this test causes additional costs without
treatment relevance if the first attempt to stop the bleeding with
sutures and Tabotamp succeeded. A splint in combination
with other hemostyptic agents such as Tabotamp and
tranexamic acid may be a very effective method especially in
patients with low compliance or in cases of INR 2.53.5 to
avoid inpatient care. The vast majority of the bleedings can be
stopped with sutures and/or Tabotamp. A very small group of
our patients needed inpatient care, if the general state was
reduced due to blood loss or the bleeding could not be con-
trolled without substitution of platelets or clotting factors.
Sex We found no gender difference in bleeding intervals.
There was only a small statistical overhang of men bleeding
after oral intervention, which could be caused by higher inci-
dence of anticoagulant therapy in the male collective (see
Table 1). This in turn could be the consequence of a disposition
to atherosclerotic plaque in male compared to female patients
[18]. In our study cohort, only a minimal gender difference was
observed with 42.0 % of male patients having anticoagulant
therapy as opposed to 39.6 % of female patients.
In conclusion, we emphasize that uncomplicated extrac-
tions are the main cause of postoperative bleeding. Open bony
wounds without soft tissue closure suffer a higher risk of
bleeding. Since most of the bleedings occur in the molar
region, we strongly recommend advising the patient how
and where to bite on gauze and to keep the patient in the
waiting room and control the wound after at least half an hour.
Most of the bleedings occurred on the same day; therefore,
projectable surgeries should be done in the beginning of the day
to allow the patient to find his/her way back to the surgeon.
Since 40 % of the patients had a history of anticoagulants and
especially the group of those taking phenprocoumon showed
very long bleeding intervals, we identify this group as a high-
risk group which needs intensified postoperative care. We
recommend controlling INR postoperatively for at least 1 week,
i.e., the initial wound healing. To further reduce the risk of
thromboembolic complications instead of stopping
phenprocoumon intake for just an oral surgery, we should look
for more potent hemostyptic agents working satisfactorily at
INR>2.5. We recommend that patients with congenital blood
disorders and patients at high risk for bleeding with the need for
substitution of platelets or clotting factors should receive inpa-
tient care.
Conflict of interest The authors declare that they have no conflict of
interest.
1661
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