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Postextraction bleeding in a hemophiliac
POSTEXTRACTION
BLEEDING
IN A HEMOPHILIAC
Report of a Case W. HARRY
ARCHER,
B.S., D.D.S., M.S.,” PITTSBURGH,
Pa.
N THE November, 1950, issue of the JOURNAL, Archer and Zubrow reported a case of hemophilia in which the antihemophilic globulin (Fraction I) was used to control hemorrhage from the alveolus following the extraction of a maxillary central incisor. In the case report presented whole blood was used to control bleeding which was primarily from the pterygoid plexus of veins that had been pierced during the so-called “zygomatic injection” to anesthetize the right maxillary third molar, and secondarily from the alveolus of this tooth after its extraction. I
Hospital Admission Notes Mr. S. P., aged 28, was admitted to the Magee Hospital with a complaint of oral bleeding, bleeding into tissues of face and neck, pain in the face and neck, and difficulty in swallowing. The symptoms followed the extraction of the right maxillary third molar thirty hours previously. Local anesthesia had been used. It was presumed the patient had been prepared for the tooth extraction by taking “calcium tablets.“f No pre-extraction coagulation time had been taken. Five hours after the extraction, the patient noticed a swelling of the right jaw. This swelling continued to increase in size, causing considerable pain so that the patient was unable to sleep. There was moderate bleeding from the extraction wound. The next morning the patient went to the Dental School from which he was referred to the hospital.
Previous History.-When the patient was 5 years old he cut his foot on a bottle. He bled from the wound for one week. At this time the diagnosis of hemophilia was made. Any small cuts which he experienced bled profusely. Sixteen years prior to this admission he had a tooth extracted. He bled from the site of this extraction for six weeks. Bleeding was stopped in the Homestead Hospital as a result of “intramuscular shots,” in the arm. Thirteen years previously he suffered a cut on the right cheek which bled for two weeks and was stopped by a pressure bandage. Later he was shot through the finger and bleeding was severe for over a week. The patient has had “rheumatoid pains” in the knees and elbows, sometimes in the hips, shoulders, and ankles, but never the wrists. The pains have *Professor of Oral Surgery, School of Dentistry, University of Pittsburgh. and Chief of the Department of Dental Surgery, Magee Hospital, Pittsburgh, Pa. tTainter, Throndson, and Richardson ,I, 2 in their investigation of the alleged hemostatic action of calcium and other agents, proved that calcium and other agents commonly advocated for hemostatic5 in dentistry are not effective when so used. These gentlemen therefore stated : “There is no justification for their continued clinical use with the hope of shortening coagulation time or reducing bleeding.” I am completely in accord with this statement. 845
846
w.
~RRY
ARCHER
never been associated with sore throat; pains began about the time the patient started to go to school. Whenever a joint becomes involved there is a marked limitation of motion for several days which is associated with pain, but after the pain has subsided the motion of the joint is practically normal. S.R.V.S. : Have no bearing on the present condition. Family History.-This patient offered the following information: On the father’s side of the family, according to the father, there were no “bleeders.” On the maternal side of the family, beginning with the present family, the patient had three brothers and three sisters, namely, J., aged 46, not a “bleeder”; F. died at the age of 11.following trauma to the lip by being struck with a baseball. Death was due to prolonged hemorrhage. R., aged 26, was a “bleeder.” In 1928 he had two teeth extracted after which he bled for thirty days. He was mapried, had one male child, aged 5, not a “bleeder.” Sisters M. and H., adults, not married, were not “bleeders.” A. died at the age of 2 in a convulsion. S., the patient, was married, had two female children aged 7 and 5, not “bleeders.” On t’he mat,ernal side of the family, the mother had three brothers and one sister. The sister, M., died in infancy. The brother J. was married, had two boys and two girls, no “bleeders.” M., married, had three boys, no “bleeders,” and none married. One brother, F., was married. F. was a “bleeder”; his wife was not a “bleeder.” They had four boys and two girls; one boy, F., a “bleeder,” married, had three boys, not “bleeders.” One girl married, M., had four girls; one of them was married and had one boy with no history obtainable. She had one boy aged 17 who was not a “bleeder.” Clinical Examination.-Examination revealed a fairly well-developed and nourished white man appearing very anxious about his present plight. The right side of the face was diffusely swollen due to a hematoma, and the right side of the neck seemed somewhat swollen. The larynx was on the left side of the neck due to the extension of the hematoma into the neck and floor of the oral cavity. Examination of the mouth revealed a large extensive extravasation of blood beneath the mucous membrane involving the right cheek, the right part of the tonsillar fossa and soft palate, the lower lip, and underneath the tongue on the right side. The floor of the mouth was elevated and with it the tongue. The cheek was moderately firm to the touch. The patient was able to talk with difficulty, he had some difficulty in breathing. There was no evidence of active hemorrhage into the mouth, although the patient did have a blood-tinged expectoration. Eyes: Pupils, equal, round, regular, react to L. and A. Nose: No discharge or obstruction. Chest: Expansion and excursion, fair. No abnormal percussions or breath sounds. Heart: Borders within normal limits; no abnormal sounds ; blood pressure, 120/70. Abdomen: No tenderness or rigidity; no palpable masses.
POSTEXTRACTION
BLEEDING
Extremities: No abnormalities. Reflexes: Within normal limits. Coagulation Tinze : 14 minutes. globin, 74 per cent.
IN A NEMOPl~lI~IAC
Blood Count : R.B.C., 3$X0,000;
847
hemo-
Progress Notes.First Day.-Fifty cubic centimeters of whole blood were injected into the right gluteal region. At 11 P.M., swelling was more pronounced and the right cheek was externally discolored. Second Day.-At 6 :30 A.M., patient was complaining of difficulty in breathSwelling was increased, with slight ecchymosis ing and inability to swallow. about the right eye. Swelling extended to the right inferior border of the mandible and anteriorly to the chin. Application of an ice bag to the face was continued.
Fig. I.-Hematoma philiac
of the right cheek and ecchymosis of right face, neck, and chest in a hemoflve days after the extraction of the right maxillary third molar.
There was no profuse bleeding from the tooth socket. Pressure pads were being kept over the socket. Pressure packing in the socket had materially controlled bleeding. Packs were carefully moistened with Monsel’s solution and dried before inserting. It was apparent that bleeding into the tissues was the result of the accidental penetration of the pterygoid plexus of veins by the needle at the time the posterior alveolar nerve was anesthetized by the so-called “zygomatic injection.” Coagulation time: 9 minutes, compared with 14 the previous day.
848
W.
HARRY
ARCHER
Third Day.-Swelling was about the same size but it was softer than before. Patient continued to complain of sensation of choking. He was quite apprehensive about the bleeding. There was very little oral bleeding. Fourth Day.-Patient reported that the pressure symptoms in his face and head were somewhat less. There was an extensive ecchymosis spreading downward over the neck and the anterior chest wall. There was still. slight seepage around the socket packing. Ecchymosis was spreading in t,he buccal mucosa, and also extraorally around the eye and face. Four hundred cubic centimeters of whole blood were given intravenously. Fifth Day.-Ecchymosis of the chest wall was very pronounced (Fig. 1). The swelling in the neck and mouth had definitely subsided. The larynx which was displaced to the left at the time of admission was now almost back in the midline. The patient was able to swallow with less difficulty and was asking for food. However, bleeding was markedly increased from the tooth socket. The packing was removed and the socket replaced with iodoform gauze saturated with a paste made from l-1,000 Adrenalin and tannic acid crystals. Then a large packing was placed over the socket. To help the patient to keep pressure on the socket, a modified Barton bandage with elastics on the sides was placed around the mandible and over the head. The patient was given 400 C.C.of blood by direct method. Sixth Day.-There was no bleeding from the tooth socket today. Ecchymosis was more marked, and the swelling in the neck was less than the day before. The patient felt much better and was encouraged. Coagulation
time:
101/, minutes.
Seventh Day.-Minor bleeding from the mouth had started again. The sputum was blood-tinged. Oral examination revealed slight oozing from around the periphery of the socket; the buccal mucosa was very edematous. The socket was repacked as described previously herein. Eighth Day.-The patient was expectorating a considerable amount of blood. The socket of the extracted tooth was not bleeding. Blood was running down the buccal mucosa. Buccal tissues of the upper jaw were too edematous for accurate observation of the origin of the hemorrhage, but it was probably comFour hundred cubic centimeters of whole ing from the site of the injection. blood were given and the bleeding stopped shortly afterward. Otherwise the patient felt better that evening. Ninth Day--There was no oral bleeding. The cheek was still very swollen and tense. The skin of the face, neck, and chest to the nipple line was markedly ecchymotic. Tenth Day.-No bleeding was present; the right cheek was not quite so swollen. The patient felt better and wanted to get out of bed. Coagulation tima: 71/s minutes. Eleventh Day.-Patient was much less apprehensive; The socket dressing was not disturbed.
mouth felt
better.
POSTEXTRACTION
BLEEDING
IN
A HEMOPHILIAC
849
Twelth Day.-Some blood expectorated the previous evening, but none today. There were no complaints. Thirteenth Day.-The mucous membrane of the cheek opposite the upper tuberosity was devoid of epithelium. Undoubtedly this was the source of the acute bleeding on the eighth day. I have observed before in easesof hematomas of the cheek following the posterosuperior alveolar nerve injection (the so-called “zygomatic injection”) that frequently there is a loss of epithelium of the buccal mucosa exposing a raw bleeding surface, ulcerous in appearance. This is probably the result of interference with the normal circulation of the epithelium because of the intense subepithelial pressure produced by the hematoma. Fourteenth to Sixteenth Day.-No bleeding was present. Swelling was gradually disappearing. Xeventeenth Day.-Joint pains were subsiding; ecchymosis was disappearing. Eighteenth Day.-Packing in socket was loose and was removed today, no bleeding. Nineteenth to Twenty-first Day.-Patient was to be discharged the next day-no complaints, no bleeding. Twenty-second Day.-The patient was discharged. He was advised not to have any teeth extracted except in a hospital.
References Hemostatic Effects of Administration of Cal1. Taintey, M. L., and Throndson, A. H.: cium, Viosterol, Styptase and Ceanothyn by Mouth, J. Am. Dent. A. 25: 638-646, 1938. 2. Tainter, M. L., Throndson, A. H., and Richardson, A. P.: Alleged Hemostatic Action of Gelatin, Coagulen, Fibrogen and Histidine Administered by Mouth, J. Am. Dent. A. 26: 420-427, 1939. 3500 FIFTH AVE.
BLEEDING
IN A HEMOPHILIAC
Report of a Case W. HARRY
ARCHER,
B.S., D.D.S., M.S.,” PITTSBURGH,
Pa.
N THE November, 1950, issue of the JOURNAL, Archer and Zubrow reported a case of hemophilia in which the antihemophilic globulin (Fraction I) was used to control hemorrhage from the alveolus following the extraction of a maxillary central incisor. In the case report presented whole blood was used to control bleeding which was primarily from the pterygoid plexus of veins that had been pierced during the so-called “zygomatic injection” to anesthetize the right maxillary third molar, and secondarily from the alveolus of this tooth after its extraction. I
Hospital Admission Notes Mr. S. P., aged 28, was admitted to the Magee Hospital with a complaint of oral bleeding, bleeding into tissues of face and neck, pain in the face and neck, and difficulty in swallowing. The symptoms followed the extraction of the right maxillary third molar thirty hours previously. Local anesthesia had been used. It was presumed the patient had been prepared for the tooth extraction by taking “calcium tablets.“f No pre-extraction coagulation time had been taken. Five hours after the extraction, the patient noticed a swelling of the right jaw. This swelling continued to increase in size, causing considerable pain so that the patient was unable to sleep. There was moderate bleeding from the extraction wound. The next morning the patient went to the Dental School from which he was referred to the hospital.
Previous History.-When the patient was 5 years old he cut his foot on a bottle. He bled from the wound for one week. At this time the diagnosis of hemophilia was made. Any small cuts which he experienced bled profusely. Sixteen years prior to this admission he had a tooth extracted. He bled from the site of this extraction for six weeks. Bleeding was stopped in the Homestead Hospital as a result of “intramuscular shots,” in the arm. Thirteen years previously he suffered a cut on the right cheek which bled for two weeks and was stopped by a pressure bandage. Later he was shot through the finger and bleeding was severe for over a week. The patient has had “rheumatoid pains” in the knees and elbows, sometimes in the hips, shoulders, and ankles, but never the wrists. The pains have *Professor of Oral Surgery, School of Dentistry, University of Pittsburgh. and Chief of the Department of Dental Surgery, Magee Hospital, Pittsburgh, Pa. tTainter, Throndson, and Richardson ,I, 2 in their investigation of the alleged hemostatic action of calcium and other agents, proved that calcium and other agents commonly advocated for hemostatic5 in dentistry are not effective when so used. These gentlemen therefore stated : “There is no justification for their continued clinical use with the hope of shortening coagulation time or reducing bleeding.” I am completely in accord with this statement. 845
846
w.
~RRY
ARCHER
never been associated with sore throat; pains began about the time the patient started to go to school. Whenever a joint becomes involved there is a marked limitation of motion for several days which is associated with pain, but after the pain has subsided the motion of the joint is practically normal. S.R.V.S. : Have no bearing on the present condition. Family History.-This patient offered the following information: On the father’s side of the family, according to the father, there were no “bleeders.” On the maternal side of the family, beginning with the present family, the patient had three brothers and three sisters, namely, J., aged 46, not a “bleeder”; F. died at the age of 11.following trauma to the lip by being struck with a baseball. Death was due to prolonged hemorrhage. R., aged 26, was a “bleeder.” In 1928 he had two teeth extracted after which he bled for thirty days. He was mapried, had one male child, aged 5, not a “bleeder.” Sisters M. and H., adults, not married, were not “bleeders.” A. died at the age of 2 in a convulsion. S., the patient, was married, had two female children aged 7 and 5, not “bleeders.” On t’he mat,ernal side of the family, the mother had three brothers and one sister. The sister, M., died in infancy. The brother J. was married, had two boys and two girls, no “bleeders.” M., married, had three boys, no “bleeders,” and none married. One brother, F., was married. F. was a “bleeder”; his wife was not a “bleeder.” They had four boys and two girls; one boy, F., a “bleeder,” married, had three boys, not “bleeders.” One girl married, M., had four girls; one of them was married and had one boy with no history obtainable. She had one boy aged 17 who was not a “bleeder.” Clinical Examination.-Examination revealed a fairly well-developed and nourished white man appearing very anxious about his present plight. The right side of the face was diffusely swollen due to a hematoma, and the right side of the neck seemed somewhat swollen. The larynx was on the left side of the neck due to the extension of the hematoma into the neck and floor of the oral cavity. Examination of the mouth revealed a large extensive extravasation of blood beneath the mucous membrane involving the right cheek, the right part of the tonsillar fossa and soft palate, the lower lip, and underneath the tongue on the right side. The floor of the mouth was elevated and with it the tongue. The cheek was moderately firm to the touch. The patient was able to talk with difficulty, he had some difficulty in breathing. There was no evidence of active hemorrhage into the mouth, although the patient did have a blood-tinged expectoration. Eyes: Pupils, equal, round, regular, react to L. and A. Nose: No discharge or obstruction. Chest: Expansion and excursion, fair. No abnormal percussions or breath sounds. Heart: Borders within normal limits; no abnormal sounds ; blood pressure, 120/70. Abdomen: No tenderness or rigidity; no palpable masses.
POSTEXTRACTION
BLEEDING
Extremities: No abnormalities. Reflexes: Within normal limits. Coagulation Tinze : 14 minutes. globin, 74 per cent.
IN A NEMOPl~lI~IAC
Blood Count : R.B.C., 3$X0,000;
847
hemo-
Progress Notes.First Day.-Fifty cubic centimeters of whole blood were injected into the right gluteal region. At 11 P.M., swelling was more pronounced and the right cheek was externally discolored. Second Day.-At 6 :30 A.M., patient was complaining of difficulty in breathSwelling was increased, with slight ecchymosis ing and inability to swallow. about the right eye. Swelling extended to the right inferior border of the mandible and anteriorly to the chin. Application of an ice bag to the face was continued.
Fig. I.-Hematoma philiac
of the right cheek and ecchymosis of right face, neck, and chest in a hemoflve days after the extraction of the right maxillary third molar.
There was no profuse bleeding from the tooth socket. Pressure pads were being kept over the socket. Pressure packing in the socket had materially controlled bleeding. Packs were carefully moistened with Monsel’s solution and dried before inserting. It was apparent that bleeding into the tissues was the result of the accidental penetration of the pterygoid plexus of veins by the needle at the time the posterior alveolar nerve was anesthetized by the so-called “zygomatic injection.” Coagulation time: 9 minutes, compared with 14 the previous day.
848
W.
HARRY
ARCHER
Third Day.-Swelling was about the same size but it was softer than before. Patient continued to complain of sensation of choking. He was quite apprehensive about the bleeding. There was very little oral bleeding. Fourth Day.-Patient reported that the pressure symptoms in his face and head were somewhat less. There was an extensive ecchymosis spreading downward over the neck and the anterior chest wall. There was still. slight seepage around the socket packing. Ecchymosis was spreading in t,he buccal mucosa, and also extraorally around the eye and face. Four hundred cubic centimeters of whole blood were given intravenously. Fifth Day.-Ecchymosis of the chest wall was very pronounced (Fig. 1). The swelling in the neck and mouth had definitely subsided. The larynx which was displaced to the left at the time of admission was now almost back in the midline. The patient was able to swallow with less difficulty and was asking for food. However, bleeding was markedly increased from the tooth socket. The packing was removed and the socket replaced with iodoform gauze saturated with a paste made from l-1,000 Adrenalin and tannic acid crystals. Then a large packing was placed over the socket. To help the patient to keep pressure on the socket, a modified Barton bandage with elastics on the sides was placed around the mandible and over the head. The patient was given 400 C.C.of blood by direct method. Sixth Day.-There was no bleeding from the tooth socket today. Ecchymosis was more marked, and the swelling in the neck was less than the day before. The patient felt much better and was encouraged. Coagulation
time:
101/, minutes.
Seventh Day.-Minor bleeding from the mouth had started again. The sputum was blood-tinged. Oral examination revealed slight oozing from around the periphery of the socket; the buccal mucosa was very edematous. The socket was repacked as described previously herein. Eighth Day.-The patient was expectorating a considerable amount of blood. The socket of the extracted tooth was not bleeding. Blood was running down the buccal mucosa. Buccal tissues of the upper jaw were too edematous for accurate observation of the origin of the hemorrhage, but it was probably comFour hundred cubic centimeters of whole ing from the site of the injection. blood were given and the bleeding stopped shortly afterward. Otherwise the patient felt better that evening. Ninth Day--There was no oral bleeding. The cheek was still very swollen and tense. The skin of the face, neck, and chest to the nipple line was markedly ecchymotic. Tenth Day.-No bleeding was present; the right cheek was not quite so swollen. The patient felt better and wanted to get out of bed. Coagulation tima: 71/s minutes. Eleventh Day.-Patient was much less apprehensive; The socket dressing was not disturbed.
mouth felt
better.
POSTEXTRACTION
BLEEDING
IN
A HEMOPHILIAC
849
Twelth Day.-Some blood expectorated the previous evening, but none today. There were no complaints. Thirteenth Day.-The mucous membrane of the cheek opposite the upper tuberosity was devoid of epithelium. Undoubtedly this was the source of the acute bleeding on the eighth day. I have observed before in easesof hematomas of the cheek following the posterosuperior alveolar nerve injection (the so-called “zygomatic injection”) that frequently there is a loss of epithelium of the buccal mucosa exposing a raw bleeding surface, ulcerous in appearance. This is probably the result of interference with the normal circulation of the epithelium because of the intense subepithelial pressure produced by the hematoma. Fourteenth to Sixteenth Day.-No bleeding was present. Swelling was gradually disappearing. Xeventeenth Day.-Joint pains were subsiding; ecchymosis was disappearing. Eighteenth Day.-Packing in socket was loose and was removed today, no bleeding. Nineteenth to Twenty-first Day.-Patient was to be discharged the next day-no complaints, no bleeding. Twenty-second Day.-The patient was discharged. He was advised not to have any teeth extracted except in a hospital.
References Hemostatic Effects of Administration of Cal1. Taintey, M. L., and Throndson, A. H.: cium, Viosterol, Styptase and Ceanothyn by Mouth, J. Am. Dent. A. 25: 638-646, 1938. 2. Tainter, M. L., Throndson, A. H., and Richardson, A. P.: Alleged Hemostatic Action of Gelatin, Coagulen, Fibrogen and Histidine Administered by Mouth, J. Am. Dent. A. 26: 420-427, 1939. 3500 FIFTH AVE.