Once identified, the bleeding site should be packed, clamped, cauterized, burnished, debrided, and/or sutured for control. Identification of the source of the bleeding requires good illumination, adequate retraction, and thorough suctioning. The usual sources for this intraoperative complication are incision into an area of granulomatous tissue, vessels in the periosteum or mucosa, or encountering nutrient arteries in the alveolar bone. During oral surgical procedures, persistent minor oozing of blood is common, although occasionally a bleeding episode prevents the continuation of the procedure and requires immediate attention. More commonly, dentists confront patients with inconvenient, nonemergent bleeding events that require a response. However, a careful clinician will rarely encounter such an event in an outpatient office setting. The process of immediate delivery of the patient to a medical facility for possible transfusions, anticoagulant reversal, and general life support measures can be initiated. Further, if the dentist is properly trained, starting an intravenous line to initiate fluid resuscitation may be advisable. If very serious, a call to an emergency service (911) may be necessary. The site may need to be packed, and the clinician will need to consider the seriousness of the event. This will likely provide temporary reduction of bleeding as a result of local vasoconstriction. If the hemorrhagic episode is difficult to manage, injection of 1/50,000 solution of epinephrine into the area may be needed. A quick mental review of the patient’s medical history is first. If an intraoperative bleeding episode is encountered, the clinician should consider several steps. Poor patient compliance with medication or postoperative instructions also are factors to be considered. Some of these hurdles include treating patients with an undisclosed or undiagnosed medical condition, improper information retrieval, or difficult surgical conditions. Multiple obstacles may prevent the implementation of the management steps listed. Although these are easily listed, application in practice can be challenging. This includes a thorough preoperative patient history, necessary medical consults, familiarity with managing patients with possible bleeding diathesis, meticulous intraoperative technique, and appropriate postoperative instructions, care, and follow-up. PERIOPERATIVE HEMORRHAGE The best management of perioperative hemorrhage is prevention. This article is a review of perioperative hemorrhage, certain available hemostatic agents, and an introduction to a new agent with good potential for application in the oral cavity. These steps are initially divided into intrinsic and extrinsic pathways, leading into a common pathway of coagulation. Figure 1 demonstrates a schematic diagram of the cascade of events leading to the formation of a fibrin clot. Nevertheless, dentists performing surgery should be familiar with these defects and their clinical manifestations. A comprehensive review of this topic is beyond the scope of this article. These defects may be genetic or acquired (Table). Not only are these agents useful for specific procedures, but they also are valuable for certain patient groups, specifically those with coagulation defects. Exodontia, tissue biopsies, placement of endosseous implants, and periodontal surgery are just some examples where hemostatic agents may be beneficial. Dentists perform a variety of surgical procedures frequently requiring the need for a hemostatic agent.
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