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Hemorrhage of the Mouth: Causes and Treatment
Epstein— Hemorrhage of the M outh 2. B u l l , F. A .: Sim ple M eth o d o f Im provin g A m algam Restorations. J .A .D .A ., 2 3 : i 8 8 o, O ctober 1936.
889 3. B u l l , F. A .: Increased Strength o f A m algam Restoration. D . D igest, 4 3 :2 8 g, June 1937. 113 4 W est State Street.
HEMORRHAGE OF THE MOUTH: CAUSES AND TREATMENT By
G asp er
M.
E p s te in ,
E M O R R H A G E in the mouth may have various causes. It m ay be a simple oozing or it m ay be very profuse; it m ay be very easily controlled or it m ay be very resistant to treatment and controlled only after a great deal of effort. T he amount o f bleeding depends not only on the cause, but also on the severity o f the cause; not only on the local condition, but also on the systemic condition. Severe bleeding can sometimes be con trolled, or its degree minimized, if certain factors are known preoperatively, such as whether there is a history of hypertension, hemophilia, a hemorrhagic diathesis or any blood dyscrasia, or any deviation from normal of the bleeding or of the coagulating tim e; whether there are any systemic disturbances, such as hyperthy roidism, cardiac disease, diabetes and nephritis, or whether the patient has re cently convalesced from an acute infec tious disease, severe or otherwise, or from a chronic debilitating condition. T h e depth of a wound is of greater importance than its exact location. Whereas mere oozing from superficial wounds m ay be controlled by pressure, a violent gush of blood, whether arterial or venous, from a deep wound requires liga tion to control it. Among the most common causes of hemorrhage in the mouth, prolonged postoperative bleeding following extrac
H
Jour. A.D.A. & D. Cos., Vol. 25, June 1938
M .D ., Chicago,
111.
tions gives the patient great concern. I f it is assumed that the only cause of the trouble is localized in the area of opera tion, it is evident that there has been an unnecessary degree o f traum a to the tis sues involved. The blood covered area is irrigated and dried as m uch as possible, with sterile gauze. I f the soft tissues have been mercilessly lacerated, as they very often are, debridement is indicated, fol lowed by the insertion o f one or more catgut sutures. I f the bleeding comes from the depths of the socket, a piece of modeling compound is warmed and pressed gently but firmly into the va cated space. T h e modeling compound is chilled with cold water and a catgut liga ture tied over it as tightly as possible. T he ligature is allowed to remain for from twenty-four to forty-eight hours, and is then removed and the wound is irrigated. T h e ligature is replaced with a gauze packing saturated with the anti septic which the operator prefers. This is continued until healthy granulation tis sue fills the wound. Pyorrhea alveolaris is common and often bleeding is the first symptom which becomes annoying enough to cause the patient to seek relief. T h e gingival m ar gins recede by erosion and the gums be come spongy and very often swollen. The extent and severity of this pathologic condition determines the amount of pres sure and trauma necessary to produce
8go
T he Journal of the American Dental Association and T h e Dental Cosmos
bleeding. The methods of treating pyor rhea are so varied and numerous that they will not be considered at this time. Large dental cavities are obvious, but smaller ones on the proximal surface may not be detected, and if they are close enough to the gingivae to cause irritation, bleeding m ay result even on brushing the teeth. Salivary calculus is usually obvious on inspection and m ay be present in large enough deposits to irritate the gingivae to develop swollen, spongy masses. In ulcerative gingivitis, more commonly known as trench mouth or Vincent’s in fection, the bleeding very often produces nausea. T h e gums are swollen and tender and bleed on the slightest provocation. T h e drugs used in treatment include the silver nitrate-iodine combinations, oxy gen-producing drugs, aniline dyes and neoarsphenamine. Fractures of the jaw, lower or upper or both, are almost invariably associated with hemorrhage. T h e amount of bleed ing depends on the extent of the involvment and the severity of the injury. I f the upper jaw is involved alone, very often the hemorrhage is into the antrum, with or without resultant epistaxis, and the soft tissues are lacerated and bruised. T h e part is allowed to rest and the mouth irrigated with warm saline or any antiseptic solution. Ice bags are applied, and ice pellets ordered for the mouth. As soon as the immediate shock of the in jury has subsided, the fracture is reduced and immobilized in the manner best suited to the location and extent and in accordance with the experience of the operator. It is not uncommon for injuries to oc cur during dental operations. T h e slip ping of a bur or a disk m ay produce a wound in the gingivae, which can be con trolled by pressure and cold sponges. On the other hand, if the floor of the mouth is injured, or the buccal mucosa lacerated to the extent of a deep wound, sutures
m ay be required to control the bleeding and approximate the edges of the wound. Angiomatous epulides are very vascu lar and bleed very readily. T h ey are best removed by electrocoagulation, actual cautery, or if the lesion is not too large, endothermy. I f the scalpel is used, the edges of the wound should be cauterized. In gingivitis gravidarum, not uncom monly, the gingivae become inflamed and spongy and bleed on the slightest provo cation. T h e condition m ay vary from a slight puffiness to the stage where the teeth are all but hidden from view by the edema. Such cases are difficult to treat and, in the light o f our present knowl edge, are best handled on an empiric basis, with astringent mouthwashes, oral hygiene, nutritious diet (avoiding all irri tating foods, such as very hot, spicy, sour and salty foods and condiments) and such measures as m ay be necessary to build up the general tonicity. Usually the symptoms disappear shortly after de livery, if not almost immediately. Degenerating leukoplakia is usually malignant. In all m alignancy o f the mouth, the bleeding, as a rule, is not due to the tumor itself, but rather to the ero sion of blood vessels by the tumor mass. T h e bleeding, therefore, would depend on the size o f the vessels eroded. I have seen spurts of blood in involvement o f the lingual artery, palatine artery, tonsillar vessels, external m axillary artery, etc. I recall a case of cavernous lymphohemangioma of the left mandible in a young girl, 18 years of age, and four months pregnant. T h e mass extended from the angle of the jaw to the mesial border of the first bicuspid, presenting a centrifugal ray-like appearance on the roentgenogram. T h e soft tissue mass in volved only the area of the last two molars, growing up and around them. T h e teeth involved were loose. W hen tissue was removed for biopsy, sufficient hemorrhage resulted to warrant ligation of the external carotid artery. A t times,
891
Epstein— Hemorrhage of the Mouth the bleeding started very suddenly with out apparent provocation and was pro fuse. T he treatment consisted in repeated electrocoagulation and two blood trans fusions. A total of five electrodesiccations were necessary before the tumor mass was completely destroyed. Incidentally, the patient gave birth to a normal child at full term. M alignant tumors, whether carcino matous or sarcomatous, cause hemor rhage by invasion of blood vessels rather than because of their inherent neoplastic nature. The treatment of malignancy of the mouth is far too large a subject to discuss here, but it m ay be said that hemorrhage caused by the tumor is best treated by ligation o f the bleeding vessel, if this is at all possible. Should this be deemed impractical, the electric spark, which has proved of value, together with electrodesiccation of the tumor mass, can be used. Some of the less common diseases which cause oral bleeding are included herewith for the sake of completeness: scurvy, acute lym phatic leukemia, H odg kin’s disease (malignant lymphoma), agranulocytosis, pernicious anemia, aplas tic anemia, hemophilia, polycythemia vera, purpura hemorrhagica and mercu rial, bismuth and iodine poisoning. Hem orrhage the result o f blood dyscrasias m ay be controlled by blood transfusions. In cases of poisoning, mentioned above, the drug is removed, warm alkaline mouthwashes are prescribed, and com pound tincture of benzoin is applied to the bleeding areas with some pressure. This m ay be followed by instructing the patient to keep ice pellets in the mouth
for from thirty to forty minutes. A saline cathartic, such as magnesium citrate, is also advisable. SU M M A R Y
Hemorrhage in the mouth m ay be of local or systemic origin. Several broad measures m ay be adopted for its control. When it is of local origin other than trau matic, pressure and soothing alkaline mouthwashes are advisable, followed by the application o f compound tincture of benzoin or a paste of tannic acid and epinephrine. I f the hemorrhage is traumatic in origin, one or more ligatures may be nec essary. I f the bleeding is on a systemic basis, it is treated as a local condition and, if necessary, the use of hemostatic sera or blood transfusion m ay be indicated. T h e electric cautery, endothermy and diathermy spark gap are therapeutic ad juncts most welcome at times to both patient and surgeon. W hether the condition is of local or systemic origin, all acid, spicy, sour, very hot and very salty foods should be avoided. Condiments are also best omitted. In all cases in which a considerable amount of blood has been lost, the patient should be urged to drink large quantities o f liquids. Both parathyroid and ovarian extracts have been injected by some as a prophy lactic or to prevent recurrent bleeding, the rationale being to increase the cal cium content of the blood with its at tendant coagulating powers. Similarly, calcium m ay be prescribed. 25 East W ashington Street.
889 3. B u l l , F. A .: Increased Strength o f A m algam Restoration. D . D igest, 4 3 :2 8 g, June 1937. 113 4 W est State Street.
HEMORRHAGE OF THE MOUTH: CAUSES AND TREATMENT By
G asp er
M.
E p s te in ,
E M O R R H A G E in the mouth may have various causes. It m ay be a simple oozing or it m ay be very profuse; it m ay be very easily controlled or it m ay be very resistant to treatment and controlled only after a great deal of effort. T he amount o f bleeding depends not only on the cause, but also on the severity o f the cause; not only on the local condition, but also on the systemic condition. Severe bleeding can sometimes be con trolled, or its degree minimized, if certain factors are known preoperatively, such as whether there is a history of hypertension, hemophilia, a hemorrhagic diathesis or any blood dyscrasia, or any deviation from normal of the bleeding or of the coagulating tim e; whether there are any systemic disturbances, such as hyperthy roidism, cardiac disease, diabetes and nephritis, or whether the patient has re cently convalesced from an acute infec tious disease, severe or otherwise, or from a chronic debilitating condition. T h e depth of a wound is of greater importance than its exact location. Whereas mere oozing from superficial wounds m ay be controlled by pressure, a violent gush of blood, whether arterial or venous, from a deep wound requires liga tion to control it. Among the most common causes of hemorrhage in the mouth, prolonged postoperative bleeding following extrac
H
Jour. A.D.A. & D. Cos., Vol. 25, June 1938
M .D ., Chicago,
111.
tions gives the patient great concern. I f it is assumed that the only cause of the trouble is localized in the area of opera tion, it is evident that there has been an unnecessary degree o f traum a to the tis sues involved. The blood covered area is irrigated and dried as m uch as possible, with sterile gauze. I f the soft tissues have been mercilessly lacerated, as they very often are, debridement is indicated, fol lowed by the insertion o f one or more catgut sutures. I f the bleeding comes from the depths of the socket, a piece of modeling compound is warmed and pressed gently but firmly into the va cated space. T h e modeling compound is chilled with cold water and a catgut liga ture tied over it as tightly as possible. T he ligature is allowed to remain for from twenty-four to forty-eight hours, and is then removed and the wound is irrigated. T h e ligature is replaced with a gauze packing saturated with the anti septic which the operator prefers. This is continued until healthy granulation tis sue fills the wound. Pyorrhea alveolaris is common and often bleeding is the first symptom which becomes annoying enough to cause the patient to seek relief. T h e gingival m ar gins recede by erosion and the gums be come spongy and very often swollen. The extent and severity of this pathologic condition determines the amount of pres sure and trauma necessary to produce
8go
T he Journal of the American Dental Association and T h e Dental Cosmos
bleeding. The methods of treating pyor rhea are so varied and numerous that they will not be considered at this time. Large dental cavities are obvious, but smaller ones on the proximal surface may not be detected, and if they are close enough to the gingivae to cause irritation, bleeding m ay result even on brushing the teeth. Salivary calculus is usually obvious on inspection and m ay be present in large enough deposits to irritate the gingivae to develop swollen, spongy masses. In ulcerative gingivitis, more commonly known as trench mouth or Vincent’s in fection, the bleeding very often produces nausea. T h e gums are swollen and tender and bleed on the slightest provocation. T h e drugs used in treatment include the silver nitrate-iodine combinations, oxy gen-producing drugs, aniline dyes and neoarsphenamine. Fractures of the jaw, lower or upper or both, are almost invariably associated with hemorrhage. T h e amount of bleed ing depends on the extent of the involvment and the severity of the injury. I f the upper jaw is involved alone, very often the hemorrhage is into the antrum, with or without resultant epistaxis, and the soft tissues are lacerated and bruised. T h e part is allowed to rest and the mouth irrigated with warm saline or any antiseptic solution. Ice bags are applied, and ice pellets ordered for the mouth. As soon as the immediate shock of the in jury has subsided, the fracture is reduced and immobilized in the manner best suited to the location and extent and in accordance with the experience of the operator. It is not uncommon for injuries to oc cur during dental operations. T h e slip ping of a bur or a disk m ay produce a wound in the gingivae, which can be con trolled by pressure and cold sponges. On the other hand, if the floor of the mouth is injured, or the buccal mucosa lacerated to the extent of a deep wound, sutures
m ay be required to control the bleeding and approximate the edges of the wound. Angiomatous epulides are very vascu lar and bleed very readily. T h ey are best removed by electrocoagulation, actual cautery, or if the lesion is not too large, endothermy. I f the scalpel is used, the edges of the wound should be cauterized. In gingivitis gravidarum, not uncom monly, the gingivae become inflamed and spongy and bleed on the slightest provo cation. T h e condition m ay vary from a slight puffiness to the stage where the teeth are all but hidden from view by the edema. Such cases are difficult to treat and, in the light o f our present knowl edge, are best handled on an empiric basis, with astringent mouthwashes, oral hygiene, nutritious diet (avoiding all irri tating foods, such as very hot, spicy, sour and salty foods and condiments) and such measures as m ay be necessary to build up the general tonicity. Usually the symptoms disappear shortly after de livery, if not almost immediately. Degenerating leukoplakia is usually malignant. In all m alignancy o f the mouth, the bleeding, as a rule, is not due to the tumor itself, but rather to the ero sion of blood vessels by the tumor mass. T h e bleeding, therefore, would depend on the size o f the vessels eroded. I have seen spurts of blood in involvement o f the lingual artery, palatine artery, tonsillar vessels, external m axillary artery, etc. I recall a case of cavernous lymphohemangioma of the left mandible in a young girl, 18 years of age, and four months pregnant. T h e mass extended from the angle of the jaw to the mesial border of the first bicuspid, presenting a centrifugal ray-like appearance on the roentgenogram. T h e soft tissue mass in volved only the area of the last two molars, growing up and around them. T h e teeth involved were loose. W hen tissue was removed for biopsy, sufficient hemorrhage resulted to warrant ligation of the external carotid artery. A t times,
891
Epstein— Hemorrhage of the Mouth the bleeding started very suddenly with out apparent provocation and was pro fuse. T he treatment consisted in repeated electrocoagulation and two blood trans fusions. A total of five electrodesiccations were necessary before the tumor mass was completely destroyed. Incidentally, the patient gave birth to a normal child at full term. M alignant tumors, whether carcino matous or sarcomatous, cause hemor rhage by invasion of blood vessels rather than because of their inherent neoplastic nature. The treatment of malignancy of the mouth is far too large a subject to discuss here, but it m ay be said that hemorrhage caused by the tumor is best treated by ligation o f the bleeding vessel, if this is at all possible. Should this be deemed impractical, the electric spark, which has proved of value, together with electrodesiccation of the tumor mass, can be used. Some of the less common diseases which cause oral bleeding are included herewith for the sake of completeness: scurvy, acute lym phatic leukemia, H odg kin’s disease (malignant lymphoma), agranulocytosis, pernicious anemia, aplas tic anemia, hemophilia, polycythemia vera, purpura hemorrhagica and mercu rial, bismuth and iodine poisoning. Hem orrhage the result o f blood dyscrasias m ay be controlled by blood transfusions. In cases of poisoning, mentioned above, the drug is removed, warm alkaline mouthwashes are prescribed, and com pound tincture of benzoin is applied to the bleeding areas with some pressure. This m ay be followed by instructing the patient to keep ice pellets in the mouth
for from thirty to forty minutes. A saline cathartic, such as magnesium citrate, is also advisable. SU M M A R Y
Hemorrhage in the mouth m ay be of local or systemic origin. Several broad measures m ay be adopted for its control. When it is of local origin other than trau matic, pressure and soothing alkaline mouthwashes are advisable, followed by the application o f compound tincture of benzoin or a paste of tannic acid and epinephrine. I f the hemorrhage is traumatic in origin, one or more ligatures may be nec essary. I f the bleeding is on a systemic basis, it is treated as a local condition and, if necessary, the use of hemostatic sera or blood transfusion m ay be indicated. T h e electric cautery, endothermy and diathermy spark gap are therapeutic ad juncts most welcome at times to both patient and surgeon. W hether the condition is of local or systemic origin, all acid, spicy, sour, very hot and very salty foods should be avoided. Condiments are also best omitted. In all cases in which a considerable amount of blood has been lost, the patient should be urged to drink large quantities o f liquids. Both parathyroid and ovarian extracts have been injected by some as a prophy lactic or to prevent recurrent bleeding, the rationale being to increase the cal cium content of the blood with its at tendant coagulating powers. Similarly, calcium m ay be prescribed. 25 East W ashington Street.