Absorbable Hemostatic Pack Effect After Primary Incisor Extraction: A Pilot Study and Introduction of a Novel Scale to Assess Post-Operative Bleeding

Objectives: This pilot study compared hemostatic pack (HP) application with no intervention following extraction of maxillary primary incisors in healthy children for effect on bleeding time and influence of patient or tooth variables utilizing a novel scale for assessment of bleeding following extraction. Study Design: A novel scale was created to assess bleeding after extraction. This scale was utilized in a randomized, split mouth study of healthy children ages 2–7 years old requiring extraction of at least 2 primary maxillary incisors under general anesthesia. One extraction site was randomly assigned to receive HP and the other had no hemostatic measures. Post-operative bleeding was rated at 2, 10, and 15 minutes post-extraction. Other variables recorded included age, sex, periapical radiolucency, presence of fistula, swelling, discoloration, intraoral stabilization device used, and vital signs at two time intervals. Pre-operative radiographs were reviewed for root resorption and periapical radiolucency. Results and Conclusions: Twenty-five patients provided 50 teeth. Hemostatic pack had a significant effect on reducing bleeding at each time point and that effect did not change over time. Age, sex, tooth pain, post-extraction heart rate, blood pressure, discoloration, amount of resorption, and presence of a periapical radiolucency had no significant effect on bleeding. The proposed bleeding scale had good intra-rater reliability and could be useful in future studies, once validated.

Hemostasis; Extractions; General anesthesia; Hemostatic pack; Bleeding time

1. Al-Bahlani S, Sherriff A, Crawford PJ. Tooth extraction, bleeding and pain control. J R Coll Surg Edinb;46(5):261-4. 2001.

2. Escamilla-Casal A, Ausucua-Ibanez M, Aznar-Gomez M, et al. Comparative study of postoperative morbidity in dental treatment under general anesthesia in pediatric patients with and without an underlying disease. Int J Paediatr Dent;26(2):141-8. 2016.

3. Hu YH, Tsai A, Ou-Yang LW, Chuang LC, Chang PC. Postoperative dental morbidity in children following dental treatment under general anesthesia. BMC Oral Health;18(1):84. 2018.

4. Levy H. Comprehensive General Dentistry In The O.R., Part 1. Journal of the New York State Academy of General Dentistry; Winter. p. 6-11. 2016.

5. Burgette JM, Quinonez RB. Cost-effectiveness of Treating Severe Childhood Caries under General Anesthesia versus Conscious Sedation. JDR Clin Trans Res;3(4):336-45. 2018.

6. Green LK, Lee JY, Roberts MW, Anderson JA, Vann WF, Jr. A Cost Analysis of Three Pharmacologic Behavior Guidance Modalities in Pediatric Dentistry. Pediatr Dent;40(7):419-24. 2018.

7. Forsyth AR, Seminario AL, Scott J, et al. General anesthesia time for pediatric dental cases. Pediatr Dent;34(5):129-35. 2012.

8. Yi Y, Lee J, Yi H, et al. Variables Affecting General Anesthesia Time for Pediatric Dental Cases. Pediatr Dent;37(7):508-12. 2015.

9. Henderson NJ, Crawford PJ, Bell CN. Blood loss following extraction of deciduous teeth under general anaesthetic. J R Coll Surg Edinb;42(5):349- 52. 1997.

10. Bridgman CM, Ashby D, Holloway PJ. An investigation of the effects on children of tooth extraction under general anaesthesia in general dental practice. Br Dent J;186(5):245-7. 1999.

11. Blacoe DA, Cunning E, Bell G. Paediatric day-case surgery: an audit of unplanned hospital admission Royal Hospital for Sick Children, Glasgow. Anaesthesia;63(6):610-5. 2008

12. Kumbargere Nagraj S, Prashanti E, Aggarwal H, et al. Interventions for treating post-e.xtraction bleeding. Cochrane Database Syst Rev;3:CD011930. 2018.

13. Ji J, Barrett EJ. Suspected intraoperative anaphylaxis to gelatin absorbable hemostatic sponge. Anesth Prog;62(1):22-4. 2015.

14. Spencer HT, Hsu JT, McDonald DR, Karlin LI. Intraoperative anaphylaxis to gelatin in topical hemostatic agents during anterior spinal fusion: a case report. Spine J;12(8):e1-6. 2012.

15. Khoriaty E, McClain CD, Permaul P, Smith ER, Rachid R. Intraoperative anaphylaxis induced by the gelatin component of thrombin-soaked gelfoam in a pediatric patient. Ann Allergy Asthma Immunol;108(3):209-10. 2012.

16. Purello-D’Ambrosio F, Gangemi S, La Rosa G, Merendino RA, Tomasello F. Allergy to gelatin. Allergy;55(4):414-5. 2000.

17. Sakaguchi M, Nakayama T, Inouye S. Food allergy to gelatin in children with systemic immediate-type reactions, including anaphylaxis, to vaccines. J Allergy Clin Immunol 1996;98(6 Pt 1):1058-61.

18. Easterbrook C, Maddern G. Porcine and bovine surgical products: Jewish, Muslim, and Hindu perspectives. Arch Surg 2008;143(4):366-70.

19. Gupta G, M RM, Kumar SP. Efficacy of Hemocoagulase as a Topical Hemostatic Agent After Dental Extractions: A Systematic Review. Cureus;10(3):e2398. 2018

20. Bajkin BV, Selakovic SD, Mirkovic SM, et al. Comparison of efficacy of local hemostatic modalities in anticoagulated patients undergoing tooth extractions. Vojnosanit Pregl;71(12):1097-101. 2014.

21. Blinder D, Manor Y, Martinowitz U, Taicher S, Hashomer T. Dental extractions in patients maintained on continued oral anticoagulant: comparison of local hemostatic modalities. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88(2):137-40.

22. American Society of Anesthesiologists House of Delegates. ASA physical status classification system. https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system. Accessed 4/20/20. 2014.

23. Fanning EA. A longitudinal study of tooth formation and root resorption. New Zealand Dent J;57:202-17. 1961.

24. McHugh ML. Interrater reliability: the kappa statistic. Biochem Med (Zagreb) 2012;22(3):276-82.

25. Kumar S, Paul A, Chacko R, Deepika S. Time required for haemostasis under pressure from dental extraction socket. Indian J Dent Res;30(6):894- 98. 2019.