Cochrane Database Syst Rev. 2018; 2018(3): CD011930. Monitoring Editor: Sumanth Kumbargere Nagraj, Faculty of Dentistry, Melaka‐Manipal Medical College, Manipal Academy of Higher Education (MAHE), Manipal, Department of Oral Medicine and Oral Radiology, Jalan Batu Hampar, Bukit Baru, MelakaMalaysia, 75150 Faculty of Dentistry, Melaka‐Manipal Medical College, (Manipal Academy of Higher Education), Department of Prosthodontics, Jalan Batu Hampar, Bukit Baru, MelakaMalaysia, 75150 King George's Medical University, Department of Prosthodontics, KGMU Campus, LucknowUttar PradeshIndia Bapuji Dental College and Hospital, Oral Medicine & Radiology, DavangereKarnatakaIndia Faculty of Dental Sciences, Sri Ramachandra University, Paediatric Dentistry, 2C Akme Park, Pedo Planet, Paediatric Dental Centre, OPP S&S POWER LTD,, PorurChennaiIndia, 600116 Faculty of Dentistry, Melaka Manipal Medical College (Manipal Academy of Higher Education), Department of Prosthodontics, Jalan Batu Hampar, MelakaMalaysia, 75150 International Islamic University Malaysia, Department of Oral Maxillofacial Surgery & Oral Diagnosis, Kulliyyah of Dentistry, Kuala LumpurMalaysia AbstractBackgroundPost‐extraction bleeding (PEB) is a recognised, frequently encountered complication in dental practice, which is defined as bleeding that continues beyond 8 to 12 hours after dental extraction. The incidence of post‐extraction bleeding varies from 0% to 26%. If post‐extraction bleeding is not managed, complications can range from soft tissue haematomas to severe blood loss. Local causes of bleeding include soft tissue and bone bleeding. Systemic causes include platelet problems, coagulation disorders or excessive fibrinolysis, and inherited or acquired problems (medication induced). There is a wide array of techniques suggested for the treatment of post‐extraction bleeding, which include interventions aimed at both local and systemic causes. This is an update of a review published in June 2016. ObjectivesTo assess the effects of interventions for treating different types of post‐extraction bleeding. Search methodsCochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health’s Trials Register (to 24 January 2018), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 12), MEDLINE Ovid (1946 to 24 January 2018), Embase Ovid (1 May 2015 to 24 January 2018) and CINAHL EBSCO (1937 to 24 January 2018). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. We searched the reference lists of relevant systematic reviews.
Selection criteriaWe considered randomised controlled trials (RCTs) that evaluated any intervention for treating PEB, with male or female participants of any age, regardless of type of teeth (anterior or posterior, mandibular or maxillary). Trials could compare one type of intervention with another, with placebo, or with no treatment. Data collection and analysisThree pairs of review authors independently screened search records. We obtained full papers for potentially relevant trials. If data had been extracted, we would have followed the methods described in the Cochrane Handbook for Systematic Reviews of Interventions for the statistical analysis. Main resultsWe did not find any randomised controlled trial suitable for inclusion in this review. Authors' conclusionsWe were unable to identify any reports of randomised controlled trials that evaluated the effects of different interventions for the treatment of post‐extraction bleeding. In view of the lack of reliable evidence on this topic, clinicians must use their clinical experience to determine the most appropriate means of treating this condition, depending on patient‐related factors. There is a need for well designed and appropriately conducted clinical trials on this topic, which conform to the CONSORT statement (www.consort‐statement.org/). Plain language summaryInterventions for managing bleeding after tooth removal Review question We conducted this review to assess different interventions for treating bleeding after tooth removal. Background After tooth extraction, it is normal for the area to bleed and then clot, generally within a few minutes. It is abnormal if bleeding continues without clot formation, or lasts beyond 8 to 12 hours; this is known as post‐extraction bleeding (PEB). Such bleeding incidents can cause distress for patients, who might need emergency dental consultations and interventions. The causes of PEB can be local, a systemic disease, or a medication. To control this bleeding, many local and systemic methods have been practised, based on the clinician's expertise. To inform clinicians about the best treatment, evidence is needed from studies where people have been randomly allocated to one of at least two different groups, which receive different treatments, or no treatment (i.e. 'randomised controlled trials' or RCTs). Study characteristics Authors working with Cochrane Oral Health updated this review of RCTs that assess interventions to treat bleeding after tooth removal. The original review was published in June 2016. For this version, we searched the medical and dental literature to 24 January 2018. We found no RCTs that met the inclusion criteria for our review. Key results and quality of the evidence This review revealed that there is no RCT evidence for the effectiveness of any available intervention for treating post‐extraction bleeding. High quality RCTs are needed to help clinicians and patients make informed choices about treatment options. Summary of findingsBackgroundDescription of the conditionTooth removal, or extraction, is one of the most common invasive oral surgical procedures carried out in routine dental practice (Van Galen 2014), and post‐extraction bleeding is a recognised, frequently encountered complication (McCormick 2014a). Immediately following the removal of a tooth, bleeding or oozing commonly occurs. This bleeding can be easily controlled in most cases (Amer 2014), and almost completely stops within eight hours of extraction. However, sometimes it may continue, resulting in a life‐threatening situation (Funayama 1994). It is important to distinguish between active bleeding from the surgical site and oozing. The active bleeding complication is commonly termed 'post‐extraction bleeding' (PEB) or 'post‐operative bleeding after extraction'. Amer 2014 has described PEB as "evidence of bleeding beyond the pressure pack". Lockhart 2003 has provided four criteria to define PEB, namely that it:
The rate of postoperative bleeding after extraction of mandibular third molars is 0.6% and after extraction of maxillary third molars is 0.4% (Chiapasco 1993). Jensen 1974 reviewed 103 cases of postoperative prolonged bleeding after oral surgery and reported that 75% of PEB occurred within eight hours of the surgery, and only four patients had coagulation deficiencies. He also reported that postoperative prolonged bleeding from the mandibular molars is more common (80%) than bleeding from the maxillary molars (20%) because of the highly vascular floor of the mouth. Wells 2000 reported that the risk of prolonged bleeding was 0.2% to 1.4% in cases of third molar removal surgery. Iwabuchi 2014 reported 2.77% clinically‐significant PEB in patients receiving warfarin therapy, and 0.39% in non‐warfarin groups, regardless of the type of teeth (95% CI 0.65% to 4.10%). Kataoka 2016 reported that the incidence of PEB ranged from 0 to 26% in their cohort study. Yagyuu 2017 reported that the risk of post‐extraction bleeding was similar for patients on direct oral anticoagulants and Vitamin K antagonist extractions. Post‐extraction bleeding has been attributed to various factors that can be broadly classified as local and systemic (McDonnell 2013; Van Galen 2014). Post‐extraction bleeding can be caused locally, from soft tissue or bone bleeding. Soft tissue bleeding can be due to traumatic extraction, leading to laceration of blood vessels (arterial, venous or capillary). Bone or osseous bleeding can be from either the nutrient canals or from the central vessels. Inflammation at the site of extraction, the presence of infection, traumatic extraction, and failure of the patient to follow post‐extraction instructions have also been associated with PEB. Systemic factors include platelet problems, coagulation disorders or excessive fibrinolysis, and inherited or acquired problems (medication induced). Post‐extraction bleeding can be categorised as primary prolonged bleeding, intermediate or reactionary prolonged bleeding, and secondary prolonged bleeding. Primary prolonged bleeding occurs during the extraction procedure, and may be due to traumatic extraction leading to laceration of blood vessels, infections, such as periapical granuloma, or injury to the bone. Patients with primary prolonged bleeding present with their mouth actively filling with blood immediately after removing the haemostatic dressing. Reactionary bleeding occurs a few hours post‐extraction and is more common in patients with systemic disorders or patients on anticoagulant therapy. Secondary bleeding (liver clots) usually occurs 7 to 10 days after extraction, and is a complication rarely encountered in dental practice (Malik 2008; Table 2). Abdullah 2014 has classified PEB as mild (oozing), moderate (bleeding persisting on the second day of extraction), and severe (any bleeding that needed hospitalisation). 1Types of bleeding after dental extractions
In this review, we considered all the definitions and classifications described above as PEB. Description of the interventionThe treatment of bleeding complications following a dental extraction is an essential skill for the dental practitioner (McCormick 2014b). Clinical decision making on how to control PEB depends on multiple factors, including the surgical location and site of bleeding, wound size, extent of bleeding, accessibility of the bleeding site, and timing of bleeding (Howe 2013). Furthermore, the selection of an intervention strategy to achieve haemostasis (blood clot formation at the site of vessel injury (Traver 2006)) also depends upon whether the patient is taking any medication or is suffering from any systemic disease, such as cirrhosis, that can affect bleeding and coagulation (McCormick 2014b). Interventions for treating PEB can be broadly categorised into local and systemic interventions. Local interventions can be further subdivided into surgical interventions, non‐surgical interventions and a combination of both. Local interventions
Systemic interventionsSystemic interventions are especially important in patients who have an associated systemic cause for bleeding. The role of local haemostatics is limited in these cases, because their use results in only temporary cessation of bleeding (Auluck 2004). Systemic interventions include administration of fresh frozen plasma (FFP), platelets, or both (Cocero 2015), factor replacement therapy, using recombinant or plasma‐derived anti‐haemophilic factor A (FVIII) or anti‐haemophilic factor B or Christmas factor (FIX) in the case of haemophilia, and plasma‐derived Von Willebrand factor (VWF)/FVIII concentrates in the case of Von Willebrand disease (Anderson 2013), intranasal desmopressin (Stanca 2010), intravenous synthetic vasopressin (Minkin 2015), oral or intravenous tranexamic acid (Morimoto 2004), oral or intravenous epsilon amino‐d‐caproic acid (Van Galen 2014). There are contradictory opinions on discontinuation of antithrombotic medications; for example, Aframian 2007 suggests the discontinuation of these medications, whereas Wahl 2016 suggests these medications for dental procedures should not be interrupted, as the prognosis of potential post‐extraction bleeding that could result from antithrombotic continuation is better than the prognosis of a potential stroke or heart attack that could follow antithrombotic interruption. How the intervention might workHaemostasis, or control of bleeding, in the oral cavity is dependent on the dynamic balance between fibrin formation and resolution and is influenced by the external environment, which contains both plasminogen and plasminogen activators (Carter 2003). It is a complex interaction between platelets, plasma proteins, and coagulation and fibrinolytic pathways. The clotting cascade involves the sequential activation of proenzymes in a stepwise response, which ultimately provides local generation of fibrin lattices that reinforce the platelet plug (Traver 2006). The coagulation process consists of three main phases: initiation, amplification, and propagation (Figure 1; Glick 2013). The initiation phase begins with injury to the endothelium and tissue factor release, ultimately leading to thrombin formation. Platelet aggregation and activation occur during the amplification phase (Glick 2013), and provide the initial haemostatic response (Traver 2006). Finally, fibrin formation and stabilisation of the platelet clot occur during the propagation phase (Glick 2013). Different phases of coagulation Different interventions to control PEB basically interfere with the clotting cascade at different levels, resulting in cessation of bleeding. The mechanism of action of various interventions can be broadly summarised, based on the different phases.
Local interventions work either mechanically or by augmenting the coagulation cascade. Haemostatic agents act to stop bleeding by causing vasoconstriction or promoting platelet aggregation, whereas tissue adhesives or sealants bind to and close defects in tissue (Traver 2006). Systemic interventions work by inhibiting fibrinolysis or promoting coagulation (Van Galen 2014). Why it is important to do this reviewCochrane Oral Health undertook an extensive prioritisation exercise in 2014 to identify a core portfolio of titles that were the most clinically important ones to maintain in the Cochrane Library (Worthington 2015). This review was identified as a priority title by the oral and maxillofacial surgery expert panel (Cochrane OHG priority review portfolio). A wide array of techniques are suggested for the treatment of PEB and different guidelines have been published (Higginson 2007; University of Cambridge). Until our first version of this review in June 2016, there had been no Cochrane review to summarise the effects of the various interventions available to treat PEB and provide evidence to guide clinical dental practice. Considering the different complex interventions addressing various outcome measures, it seems important to attempt to describe the components of interventions and to identify effective intervention strategies. A systematic review can inform the implementation of different approaches and trigger the development of new interventions on the basis of current best evidence. A systematic review on this topic is also needed since interventions of questionable effectiveness and unclear consequences might be in use. ObjectivesTo assess the effects of interventions for treating different types of post‐extraction bleeding. MethodsCriteria for considering studies for this reviewTypes of studiesWe considered randomised controlled trials (RCTs) evaluating any intervention for treating post‐extraction bleeding (PEB). We excluded quasi‐RCTs, cross‐over trials and preventive trials. We had planned to include split‐mouth studies, provided there was no possibility of contamination. Split‐mouth design is one of the self‐controlled study designs that is unique to dentistry. The design is characterised by subdividing the mouth of the subject into homogeneous within‐patient experimental units such as quadrants, sextants, contralateral or ipsilateral quadrants or sextants, or a symmetrical combination of these. Types of participantsWe considered trials with participants of any age and either gender, who reported PEB, regardless of the type of teeth (anterior or posterior, mandibular or maxillary).
Types of interventionsWe considered any surgical or non‐surgical technique or material used for the treatment of PEB. We had planned to make the following comparisons.
Types of outcome measures
Primary outcomes
Secondary outcomes
Search methods for identification of studiesElectronic searchesCochrane Oral Health’s Information Specialist conducted systematic searches in the following databases for randomised controlled trials and controlled clinical trials without language or publication status restrictions:
Subject strategies were modelled on the search strategy designed for MEDLINE Ovid. Where appropriate, they were combined with subject strategy adaptations of the highly sensitive search strategy designed by Cochrane for identifying randomised controlled trials and controlled clinical trials as described in the Cochrane Handbook for Systematic Reviews of Interventions Chapter 6 (Lefebvre 2011). Due to the Cochrane Centralised Search Project to identify all clinical trials in the database and add them to CENTRAL, only most recent months of the Embase database were searched at the review's inception, and this search was updated for this version of the review. See the searching page on the Cochrane Oral Health website for more information. No other restrictions were placed on the date of publication when searching the electronic databases. Searching other resourcesThe following trial registries were searched for ongoing studies:
We searched the reference lists of relevant systematic reviews for further studies. We did not perform a separate search for adverse effects of interventions. Data collection and analysisSelection of studiesThree pairs of review authors (Ashok L (AL) and Prashanti Eachempati (PE), Himanshi Aggarwal (HA) and Kiran Kumar (KK), and Muthu MS (MMS) and Haszelini Hassan (HH)), independently and in duplicate, screened the titles and abstracts from the electronic searches to identify potentially eligible studies. The search was designed to be sensitive and include controlled clinical trials; these were filtered out early in the selection process if they were not randomised. We obtained full‐text copies of all eligible and potentially eligible studies, which were independently evaluated by two authors (Sumanth Kumbargere Nagraj (SKN) and PE) . We resolved disagreements by discussion. When resolution was not possible, we consulted an arbiter (Adinegara Lutfi Abas). We assessed articles in languages other than English after the abstracts had been translated (Table 2). We did not find any trials that fulfilled the inclusion criteria. Data extraction and managementWe had planned that two review authors (SKN, PE) would independently extract the data; and would not have been blinded to the authors. We would have resolved any disagreements by discussion between the two review authors, if necessary, consulting a third review author (PE) in order to reach consensus. We had planned to extract data using a customised data extraction form. All the items in the data extraction form were designed following guidance from the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We would have entered study details into the 'Characteristics of included studies' table in Review Manager (RevMan) software (RevMan 2014), recording the following details for each included trial:
We had planned to write, email or telephone the contact author of included studies when clarification of details or additional data were required. Assessment of risk of bias in included studiesTwo review authors (SKN and PE) had planned to independently assess the risk of bias in the included trials in seven domains:
For each of these components, we had planned to assign a judgment regarding the risk of bias as either high, low, or unclear based on guidance in Higgins 2011. We had planned to contact the trial authors if details were missing or unclear, and resolve disagreements through consensus. We had planned to record our judgements and justifications in 'Risk of bias' tables for each included study and generate a 'Risk of bias' summary graph and figure. We would have used these judgements to grade the overall quality of evidence for each comparison and outcome in the 'Summary of findings' tables. We had planned to summarise the risk of bias according to Higgins 2011; see Table 3. 2Summarising the risk of bias for a body of evidence
Measures of treatment effectWe had expected our primary outcome to be expressed in dichotomous data. We would have expressed the effect estimate as a risk ratio (RR) with 95% confidence intervals (CI). We had expected our secondary outcomes to be presented as dichotomous data, continuous data, or ordinal scales. We had planned to use means and standard deviations to calculate mean differences and 95% CI for continuous data measured with the same scales and standardised mean differences if studies used different scales to measure the same outcome. If data were expressed in ordinal scales, we had planned to explore the possibility of converting them to dichotomous outcomes. If outcomes were reported at baseline, trial endpoints, or follow‐up, we had planned to extract the mean change and standard deviation from baseline for each treatment group. We had intended to pool either end scores or change scores, but preferred end scores when available; we would have combined end and change scores where necessary. We had planned to analyse data expressed as counts (number of bleeding incidents) in the same way as continuous data. Unit of analysis issuesWe expected two types of non‐standard study designs in this review:
We were expecting data related to repeated observation on participants for our secondary outcome of time required for the control of bleeding. In this case, we had planned to follow the method described in section 9.3.4 of the Cochrane Handbook (Higgins 2011). In trials where adverse effects were described as counts, we wanted to follow the method described in section 9.2.5 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). In the case of dropouts, we had planned to use what the paper reports and deal with it in the 'Risk of bias' assessment. We were not expecting to find any cluster‐randomised trials for this condition. Dealing with missing dataWe had planned to contact study authors to obtain missing data. We would have used the methods outlined in section 16.1.2 of the Cochrane Handbook for Systematic Reviews of Interventions to calculate missing standard deviations. If it had not been possible to calculate the SDs, we would have described the outcomes qualitatively (Higgins 2011). Assessment of heterogeneityIf meta‐analyses were performed, we would have assessed heterogeneity using a Chi² test, where a P value < 0.1 indicated statistically significant heterogeneity. We would have quantified heterogeneity using the I² statistic as follows:
If there was considerable heterogeneity (I² > 75%), which could not be explained by the subgroup analyses, we planned not to conduct meta‐analysis. We had planned to interpret I² values between 0% to 40% as possibly insignificant, 30% to 60% as possibly significant, 50% to 90% as possibly substantial, and 75% to 100% as possibly very substantial ('considerable'); depending on whether the inconsistency in results was due to differences in the direction of effect estimates between trials rather than due to differences in the magnitude of effect estimates favouring an intervention (Deeks 2011). Assessment of reporting biasesIf there were more than 10 studies included in a meta‐analysis, we had planned to assess the possible presence of reporting bias by testing for asymmetry in a funnel plot. If present, we would have carried out statistical analyses using the methods described by Egger 1997. Data synthesisWe had planned to analyse the data using RevMan software (RevMan 2014). If the data available from the studies had similar comparisons and outcomes, we would have undertaken a meta‐analysis. Our general approach would have been to use a random‐effects model. With this approach, the CIs for the average intervention effect are wider than those obtained using a fixed‐effect approach, leading to a more conservative interpretation. We wanted to use all end scores or all change scores when available, but would have combined end and change scores where necessary, using the criteria in section 9.4.5.2 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We had planned to report the results from studies not included in a meta‐analysis in additional tables. Subgroup analysis and investigation of heterogeneityIf there was significant heterogeneity, we had planned to explore the reasons by performing the following subgroup analyses based on different groups of patients. The subgroups were to be divided based on:
Sensitivity analysisIf there were sufficient included studies, we would have undertaken sensitivity analysis based on risk of bias, including only studies at low risk of bias. Summarising findings and assessing the quality of the evidenceWe had planned to use the GRADE approach to interpret findings (Schunemann 2008). We had planned to use GRADE Profiler software (GRADEpro GDT 2014), and import data from RevMan 2014 to create 'Summary of findings' tables for each comparison included in the review. These tables were to provide information concerning the overall quality of the evidence from the trials, the magnitude of effect of the interventions examined, and the sum of available data on the primary and secondary outcomes. The GRADE approach considers ‘quality’ to be a judgment of the extent to which we can be confident that the estimates of effect are correct (Schunemann 2008). A body of evidence from randomised controlled studies is initially graded as high and downgraded by one or two levels on each of five domains, after full consideration of: any limitations in the design of the studies, the directness (or applicability) of the evidence, the consistency of results, precision of the results, and the possibility of publication bias. A quality level of 'high' reflects confidence that the true effect lies close to that of the estimate of the effect for an outcome. A judgement of 'moderate' quality indicates that the true effect is likely to be close to the estimate of the effect, but acknowledges the possibility that it could be substantially different. 'Low' and 'very low' quality evidence limit our confidence in the effect estimate (Balshem 2011). ResultsDescription of studiesWe found no published or ongoing randomised controlled trials that evaluated interventions for treating post‐extraction bleeding. Results of the searchOur search strategy identified 1916 titles and abstracts of studies up to 24 January 2018. These were independently assessed for relevance by three pairs of review authors (AL and PE; HA and KK; MMS and HH). We checked the reference lists of the excluded studies and added another 24 references. After removal of duplicates, we had a total of 1187 records. We rejected 1147 based on the abstracts. We obtained full texts for other 40 trials. Twenty‐eight of these were not RCTs (studies not in English that we translated are listed in Appendix 8). We excluded the other 12 trials for reasons described below. None of the trials met the inclusion criteria for our review (Figure 2). Included studiesWe did not find any studies suitable for inclusion. Risk of bias in included studiesNo trials were included. Effects of interventionsSee: Table 1 Summary of findings for the main comparisonSummary of findings for interventions to treat post‐extraction bleeding
No studies fulfilled our inclusion criteria. DiscussionPost‐extraction bleeding (PEB) is one of the treatment complications of dental extraction that might make a patient panic and seek immediate dental consultation. With the increasing number of patients on anticoagulant therapy with aspirin, warfarin, and clopidogrel, the chance of encountering PEB is increasing. Usually, these people are aware of their medical condition and report their medical history. It is normal to use precautionary measures to prevent PEB in such patients. However, this may not be the situation in low‐ and middle‐income countries, where the majority of patients may not give a proper medical and drug history, and medical records may not be accessible. Hence, it is important to know how to control PEB in cases where no preventive measures were used. Post‐extraction bleeding can also occur due to local or systemic problems that are not expected in routine dental extractions. We do not have any evidence‐based guidelines to manage such cases. The present review aimed to assess the effects of various interventions for the treatment of different types of PEB. We did not find any suitable trials to include in our review. This is because most of the trials advocated preventive measures prior to and immediately after extraction, and reported either the incidence of PEB or tested preventive measures. Most of these trials reported the management of PEB based on clinician experience. Several trials tested whether anticoagulants, antiplatelets, or antifibrinolytics should be stopped before dental extraction, and reported varying incidence rates of PEB in control and intervention groups. The majority of the preventive trials randomised extraction cases into intervention groups. An ideal trial for this review would randomise PEB (primary or reactionary or secondary) cases instead. This topic seems to be an unexplored area of primary research. We found one observational trial in a German clinical trial register in which postoperative bleeding incidents after dental treatment in patients with and without anticoagulant therapy were studied (DRKS00009286). We found no non‐Cochrane systematic reviews on this topic. We identified two narrative reviews based on the authors' opinions (Leonard 1995; McCormick 2014a). We found two websites that have published guidelines to manage PEB (Emed handbook by Higginson 2007; University of Cambridge). We observed the term 'post‐extraction bleeding' being used in different ways. Joshi 2014 used PEB terminology to describe the normal bleeding that happens after dental extraction in their study. Al‐Bahlani 2001 describes any type of bleeding after dental extraction as postoperative bleeding. This can create confusion and there is a need to standardise PEB terminology and its definition. Authors' conclusionsImplications for practiceWe identified no published or ongoing randomised controlled clinical trials on interventions to treat post‐extraction bleeding, so it is not possible to present evidence to clinicians or patients. In the absence of any evidence from randomised controlled trials, clinicians should base their decisions on clinical experience, in conjunction with evidence from preventive trials. Implications for researchThere is a need for robust clinical trials to evaluate the effects of interventions for the treatment of PEB. Future randomised controlled trials should focus on interventions to control bleeding in patients after the extraction, and in whom no preventive interventions have been advocated. This will help us understand the best intervention strategy to be used if an emergency situation arises post‐extraction, to control primary, secondary or reactionary haemorrhage. Considering the varying incidence of PEB (0% to 26%), multicentric trials to achieve appropriate sample size (power of the study) should be conducted. Any future trials should be well designed and reported according to the CONSORT statement (http://www.consort‐statement.org/). What's new
HistoryProtocol first published: Issue 10, 2015
NotesThis review will no longer be updated as there are no completed or ongoing randomised controlled trials evaluating treatments for post‐extraction bleeding. AcknowledgementsThe authors would like to thank Pradeep Kumar for screening the titles and abstracts for the previous version of this review. The authors thank Ms. Anne Littlewood, Information Specialist, Ms. Janet Lear, Administrator, Ms. Laura CI MacDonald, Managing Editor, and Ms. Helen Wakeford, Deputy Managing Editor, all of Cochrane Oral Health. We thank Philip Riley and Ruth Floate for their comments. We also thank Ms. Shazana Binti Mohd Selva, Chief Librarian, Dr. Venkatachalapathy Suram, Professor, Professor Dr.Adinegara Lutfi Abas, Dean, Faculty of Medicine, Professor Dr. Abdul Rashid Haji Ismail, Dean, Faculty of Dentistry, Melaka Manipal Medical College, Manipal Academy of Higher Education, Melaka, Malaysia, and Professor Dr. Ravi Kant, Vice Chancellor, King George's Medical University, Lucknow, India for all the suggestions and help during the review preparation. We also thank Dr. Naresh Yedthare Shetty, Senior Lecturer, International Medical University, Kuala Lumpur for his valuable suggestions. We acknowledge the help of foreign language translators Joanna Zajac, Malgorzata Bala, Paul Tramini, Lilia Ziganshina, Karin Rau, Anette Blümle, Anna Misyail Abdul Rashid, Loh Zheng Tao, Giovanni Lodi, Andrea Pokorna, Maddalena Manfredi, Ubai Alsharif, Dr Liyuan Ma, Professor Chengge Hua, and Professor Zongdao Shi. AppendicesAppendix 1. Cochrane Oral Health's Trials Register search strategy
Appendix 2. The Cochrane Central Register of Controlled Trials (CENTRAL) search strategy#1 [mh ^"Tooth extraction"] Appendix 3. MEDLINE Ovid search strategy1. Tooth extraction/ This subject search was linked to the Cochrane Highly Sensitive Search Strategy (CHSSS) for identifying randomised trials in MEDLINE: sensitivity‐maximising version (2008 revision) as referenced in Chapter 6.4.11.1 and detailed in box 6.4.c of The Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0 [updated March 2011] (Lefebvre 2011). 1. randomized controlled trial.pt. Appendix 4. Embase Ovid search strategy1. Tooth extraction/ This subject search was linked to an adapted version of the Cochrane Centralised Search Project filter for identifying RCTs in Embase Ovid (see http://www.cochranelibrary.com/help/central‐creation‐details.html for information): 1. Randomized controlled trial/ Appendix 5. CINAHL EBSCO search strategyS13 S8 and S12 This subject search was linked to Cochrane Oral Health’s filter for CINAHL EBSCO: S1 MH Random Assignment or MH Single‐blind Studies or MH Double‐blind Studies or MH Triple‐blind Studies or MH Crossover design or MH Factorial Design Appendix 6. US National Institutes of Health Trials Registry (ClinicalTrials.gov) search strategy“oral surgery” and bleed “oral surgery” and hemorrhage tooth and extraction and bleed tooth and extraction and hemorrhage Appendix 7. The WHO International Clinical Trials Registry Platform search strategyOral surgery and bleed Oral surgery and hemorrhage Oral surgery and haemorrhage Tooth extraction and bleed Tooth extraction and hemorrhage Tooth extraction and haemorrhage Appendix 8. Studies we translated and rejected as ineligible for inclusion
NotesStable (no update expected for reasons given in 'What's new') Characteristics of studiesCharacteristics of excluded studies [ordered by study ID]Differences between protocol and reviewWe changed the title from 'managing' to 'treating'. We made this change throughout as 'managing' could be interpreted as including prevention, which was not our intention. Figure 1 in the protocol has been modified to Table 1 in the review ('Types of bleeding after dental extractions'). Primary and secondary outcomes are re‐worded without changing the meaning. We had mentioned under selection of studies that two pairs of review authors would independently screen the titles and abstracts to identify potentially eligible studies. However, three pairs of review authors screened the titles and abstracts. As we did not have any included trials, the contribution of authors differed from what we had planned. Contributions of authors
Sources of supportInternal sources
External sources
Declarations of interestSumanth Kumbargere Nagraj: no interests to declare ReferencesReferences to studies excluded from this reviewAk 2012 {published data only}
Al‐Mubarak 2006 {published data only}
Carter 2003 {published data only}
CTRI/2017/09/009784 {unpublished data only}
Henderson 1998 {published data only}
Howard 1973 {published data only}
Kjellman 1973 {published data only}
Medeiros 2011 {published data only}
NCT02918045 {published data only}
NCT03108365 {published data only}
Pinsent 1986 {published data only}
Zhou 1985 {published data only}
Additional referencesAbdullah 2014
Aframian 2007
Al‐Bahlani 2001
Al‐Belasy 2003
Amer 2014
Anderson 2013
Antoszewski 1972
Auluck 2004
Bajkin 2014
Baumann 2009
Chiapasco 1993
Cocero 2015
Deeks 2011
DRKS00009286
Egger 1997
Fetkowska‐Mielnik 1969
Funayama 1994
Glick 2013
GRADEpro GDT 2014 [Computer program]
Higgins 2011
Higginson 2007
Howe 2013
Iwabuchi 2014
Jensen 1974
Joshi 2014
Kataoka 2016
Khomiachenko 1978
Lefebvre 2011
Leonard 1995
Lockhart 2003
Malik 2008
Marini 1966
Martineau 1989
McCormick 2014a
McCormick 2014b
McDonnell 2013
Mingarro‐de‐León A 2014
Minkin 2015
Morimoto 2004
Neuner 1968
Pavek 1976
Perdigão 2012
Pippi 2015
RevMan 2014 [Computer program]
Rokicka‐Milewska 1966
Saltykova 1974
Scarano 2014
Sharma 2017
Soltani 2014
Stanca 2010
Szpirglas 1979
Torteli 1965
Traver 2006
Trentalancia 1967
University of Cambridge
Van Galen 2014
Wahl 2016
Wells 2000
Worthington 2015
Yagyuu 2017
References to other published versions of this reviewSumanth 2015
Sumanth 2016
Articles from The Cochrane Database of Systematic Reviews are provided here courtesy of Wiley How long after a tooth extraction should it stop bleeding?Bleeding should continue for up to 24 hours
It is normal for bleeding to exist for up to 24 hours after the tooth extraction. However, the bleeding should be minimal and tolerable, and excessive bleeding that causes a major distraction or that causes major discomfort that is not tolerable is a concern.
Can I go to sleep if my tooth extraction is still bleeding?Sleeping on the back is necessary for ensuring any materials used to control the bleeding in the extraction site will not shift out of place. Keeping the head to the side while sleeping could cause the protective materials to shift a small bit, making it harder for the teeth to stay healthy.
What happens if bleeding doesn't stop after tooth extraction?In some cases, residual bleeding may continue up to 24 hours after the extraction. Seeing a small amount of blood periodically appear is normal. If excessive bleeding continues, a patient should reach out to the dentist as soon as possible.
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