ORAL & MAXILLOFACIAL SURGERY 1

Paper – I (Physiology)

Explain types of bleeding. Describe the intrinsic and extrinsic pathways and
methods to control bleeding. (10 marks)

ANSWER

CONTENTS/ SYNOPSIS
Introduction
Types of bleeding
1. Basis: source of bleeding
2. Basis: nature of bleeding vessel
3. Basis: time of hemorrhage
4. Basis: volume of blood loss
5. Basis: speed of blood loss
6. Basis: degree of hemorrhage
7. Basis: type of intervention
Etiology
Hemostasis
Coagulation cascade
1. Intrinsic and Extrinsic pathway
Methods to control bleeding
1. Mechanical
2. Chemical
a. Local agents
b. Systemic agents
3. Thermal
References

INTRODUCTION

• Bleeding or haemorrhage denotes the escape of blood from a blood vessel.

• Any damage to the vasculature leads to the outflow of blood
• Loss of blood due to any reason beyond a certain point is potentially life
threatening and may lead to exsanguination (blood loss to a degree sufficient
to cause death

TYPES OF BLEEDING
• Bleeding or haemorrhage can be classified in many ways:
©MDS Made [Link]
drpnnreddy@[Link]
 ORAL & MAXILLOFACIAL SURGERY 2
Paper – I (Physiology)

Basis: source of bleeding

i) External/ Revealed Hemorrhage: When bleeding is revealed and seen
outside, e.g. epistaxis.
ii) Internal/ Concealed Hemorrhage: Bleeding is concealed and not seen
outside, e.g. intracranial hematoma. Concealed hemorrhage may become
revealed as in haemetemesis or melaena in peptic ulcer bleed

Basis: nature of bleeding vessel

i) Arterial Hemorrhage: Bright red in color; blood emitted as a jet with each
heartbeat → difficult to control.
ii) Venous Hemorrhage: Dark red in color; steady and copious blood flow,
color becomes darker with oxygen desaturation → Usually easy to control.
iii) Capillary Hemorrhage: Bright red in color. Generalized ooze of blood
instead of blood flow → Easy to control

Basis: time of hemorrhage

i) Primary Hemorrhage:
▪ Occurs at the time of trauma or surgery
▪ Cause: injury to vessels
▪ Maybe arterial, venous or capillary
ii) Reactionary Hemorrhage:
▪ Occurs within 24 hours of trauma or operation.
▪ Cause: slippage of ligature, clot dislodgement, cessation of reflex
vasospasm
▪ Bleeding starts when there is rise in blood pressure
iii) Secondary Hemorrhage:
▪ Occurs after 7 – 14 days of trauma or operation.
▪ Cause: sloughing of vessel due to infection, pressure necrosis or
malignancy

Basis: volume of blood loss

i) Mild Hemorrhage: Blood loss ≤ 500 mL.
ii) Moderate Hemorrhage: Blood loss 500 – 1000 mL.
iii) Severe Hemorrhage: Blood loss ≥ 1 L.

Basis: speed of blood loss

i) Acute Hemorrhage: Massive bleeding in short span of time.
©MDS Made [Link]
drpnnreddy@[Link]
 ORAL & MAXILLOFACIAL SURGERY 3
Paper – I (Physiology)

ii) Chronic Hemorrhage: Slow bleeding small in quantity for long time.

Basis: degree of hemorrhage

i) Class I: Up to 15% blood volume loss
ii) Class II: Between 15 – 30% blood volume loss
iii) Class III: Between 30 – 40% blood volume loss
iv) Class IV: More than 40% blood volume loss

Basis: type of intervention

i) Surgical Haemorrhage: is the result of injury and amenable to surgical control,
or from angioembolism.
ii) Non-Surgical Haemorrhage: is general ooze from all raw surface due to
coagulopathy, it cannot be stopped by surgical means, require correction
coagulation abnormalities.

ETIOLOGY
• Trauma.
• Infections.
• Congenital malformations.
• Surgical (intraoperative/postoperative).
• Due to systemic diseases (viral infection, scurvy, allergy).
• Abnormalities in clotting factor (hemophilia A, multiple myeloma).
• Abnormalities in platelets (leukemia, ITP, thrombocytosis, thrombocytopenia).

HEMOSTASIS
• Mechanism of cessation of extravasation of blood.
• Four steps:
o Injured blood vessel undergoes constriction due to spasm.
o Activation of platelets and formation of platelet plug→ primary
hemostasis.
o Activation of clotting mechanism and formation of clot → secondary
hemostasis.
o Fibrous organization of clot or retraction of clot.

COAGULATION CASCADE

©MDS Made [Link]

drpnnreddy@[Link]
 ORAL & MAXILLOFACIAL SURGERY 4
Paper – I (Physiology)

• Activation of clotting process in plasma that results in formation of fibrin which

strengthens the primary hemostatic plug.
• Completed in several minutes and is important in bleeding from larger vessels.
• Procoagulants: substances promote clotting ; anticoagulants : prevent clotting
• There is a complex interaction of various factors of coagulation in the
formation of a clot.

Coagulation Mechanism
• Series of 4 reactions:
o Reaction 1:
▪ Intrinsic or contact phase of coagulation.
▪ Factors VIII, IX, XI, XII along with calcium and plasma proteins
take part.
▪ Partial thromboplastin time screens this.
o Reaction 2:
▪ Extrinsic pathway for initiation of coagulation.
▪ Release of tissue thromboplastin from injured tissues.
▪ Protease complex formed between factor VII, calcium and tissue
thromboplastin, which activates factor X.
▪ Prothrombin time screens this.
o Reaction 3:
▪ Factor X is activated by proteases generated in the previous two
reactions.
o Reaction 4:
▪ Prothrombin is converted into thrombin in presence of factor V,
calcium and phospholipids.
▪ Main role of thrombin is conversion of fibrinogen into fibrin.
▪ It also activates factor V, VIII and XIII and helps in platelet
aggregation and secretion.

Intrinsic and Extrinsic pathway

©MDS Made [Link]

drpnnreddy@[Link]
 ORAL & MAXILLOFACIAL SURGERY 5
Paper – I (Physiology)

METHODS OF ACHIEVING HEMOSTASIS

1. Mechanical Methods
o Pressure.
o Hemostat.
o Sutures and Ligation.
o Surgical staples and ligating clips
o Transcatheter arterial embolization
2. Chemical Methods
o Local Agents:
▪ Adrenaline.
▪ Thrombin.
▪ Surgicel.
▪ Oxycel.
▪ Surgicel Fibrillar.
▪ Gelatine Sponge.
▪ Microfibrillar Collagen.
▪ Fibrous Glue.

©MDS Made [Link]

drpnnreddy@[Link]
 ORAL & MAXILLOFACIAL SURGERY 6
Paper – I (Physiology)

▪ Styptics and Astringents.

▪ Alginic Acid.
▪ Natural Collagen Sponge.
▪ Bone Wax.
▪ Ostene.
o Systemic Agents:
▪ Ethamsylate
▪ Tranexamic acid
▪ Whole Blood.
▪ Platelet Rich Plasma.
▪ Fresh Frozen Plasma.
▪ Cryoprecipitate.
3. Thermal Agents
o Cautery.
o Electrocautery.
o Cryosurgery.
o Lasers.

Mechanical methods
Pressure
• Immediate measure for capillary or venous bleeding.
• Firm pressure should be applied over the bleeding site using either fingers or
gauze for at least 5 minutes.
• This would control most hemorrhages by counteracting the hydrostatic
pressure of the bleeding vessel.

Haemostat
• Application of haemostat at the bleeding point helps in direct occlusion of the
bleeding vessel

Sutures and ligation

• Severed blood vessels may be tied with ligatures.
• A ligature replaces the hemostat as a permanent method of effective
hemostasis.
• For large pulsatile artery, a trans – fixation suture to prevent slipping is
indicated.

©MDS Made [Link]

drpnnreddy@[Link]
 ORAL & MAXILLOFACIAL SURGERY 7
Paper – I (Physiology)

• Non – resorbable sutures such as silk and polyethylene are used as they
evoke less tissue reaction

Surgical staples and ligating clips

• Staples → sterile and disposable
• steel and titanium staples available
• Ligating clips→ quick and easy
• decrease foreign body reaction
• various sizes
• expensive compared to sutures.

Trans catheter arterial embolization

• Restricts tumors blood supply .
• Arterial embolization preferentially interrupts tumors blood supply and stalls
growth until neovascularization
• Used to control bleeding in Hemangiomas

Chemical methods
Local Agents:
Adrenaline
• Topical application of adrenaline brings about vasoconstriction of bleeding
capillaries.
• Available in ampoule, which is applied with the help of gauze.
• Concentration of 1:1000 is used for hemostasis over the oozing site.

Thrombin
• Helps in converting fibrinogen into fibrous clot.

Surgicel
• Oxidized cellulose polymer obtained by dissolving pure alpha- cellulose in an
alkaline solution.
• Acts by forming acid products from partial dissolution that coagulates the
plasma proteins to form a black or brown sticky gelatinous clot.
• Applied surgicel resorbs from the site in 4 to 8 weeks.
• Disadvantage : surgicel clot is not formed by normal physiological mechanism.

Surgicel fibrillar
©MDS Made [Link]
drpnnreddy@[Link]
 ORAL & MAXILLOFACIAL SURGERY 8
Paper – I (Physiology)

• Modified surgicel or oxidised regenerated cellulose in layers that can be

adapted to irregular surfaces and inaccessible areas.
• Complete resorption occurs in 2 weeks.

Gelatine sponge or gelfoam or surgifoam:

• Formed from purified pork skin gelatin.
• Completely absorbable material.
• Has the capacity to absorb 45 times its weight in blood.
• Resorbs completely in 4 to 6 weeks.

Oxycel
• Oxidized cellulose polymer product.
• This absorbable hemostatic material is manufactured by controlled oxidation of
cellulose using nitrous dioxide.
• Cellulosic acid present in it has affinity for hemoglobin which leads to the
formation of artificial clot.
• Should be applied on the dry surface as the acid formed during the wetting
process inactivates the thrombin.
• The platelets plug into its meshwork like surface & helps in clot formation.

Microfibrillar collagen (avitene)

• Collagen derived from bovine skin cause contact activation in addition to direct
platelet aggregation.
• Absorption time is 3 months.

Fibrin glue
• Biological adhesive which contains thrombin, fibrinogen, factor XIII, aprotinin.
• Thrombin converts fibrinogen to unstable fibrin clot, factor XIII stabilizes the
clot and aprotinin prevents its degradation.

Styptics & astringents

• Precipitates protein & arrests bleeding.
• Commonly used styptics & astringents are Monsel’s solution containing ferric
subsulfate & tannic acid.
• Thrombin & gelatin sponge are now widely used.

Alginic acid
©MDS Made [Link]
drpnnreddy@[Link]
 ORAL & MAXILLOFACIAL SURGERY 9
Paper – I (Physiology)

• Placed over the bleeding sites

• Forms protective film over the bleeding site→ film compresses the capillaries
& stabilizes the blood clot.

Natural collagen sponge

• White sponge material
• fully absorbable
• stimulates the platelet aggregation
• Activates coagulation factors XI & XIII.

Fibrin sponge
• Obtained from bovine material.
• Chemically treated to avoid allergic reactions.
• Applied on the bleeding site especially in post extraction socket.
• Fully absorbed by the tissues within 4-6 weeks.

Ostene
• water soluble bone hemostatic agent
• alkylene oxide copolymers
• no incidence of adverse response in the cortical defect site, medullary cavity
or the surrounding tissue.

Bone Wax
• Sterilized, non – absorbable mix of waxes.
• Consists of seven parts by weight of wax (white bees wax, paraffin wax & an
isopropyl ester of palmitic acid), two parts of olive oil and one part of phenol.
• Indicated in cases of bleeding from the bone or from chipped edges of bone.
• Bone wax is softened with the fingers to desired consistency & then applied
over the bleeding site.
• Its hemostatic mechanism is through mechanical obstruction of the osseous
cavity containing the bleeding vessels.

Botroclot Haemocoagulase
• A proteolytic enzyme from venom of South American viper, Bothrops atorox,
• plasma clotting agent for fibrinogen
• Indications: Topical capillary bleeding & tissue oozing
• Hastens coagulation through multiple actions
©MDS Made [Link]
drpnnreddy@[Link]
 ORAL & MAXILLOFACIAL SURGERY 10
Paper – I (Physiology)

• Promotes cosmetically elegant, scarless wound healing

• Arrests bleeding in cuts and wounds, Surgical incisions, Skin Grafting (Donor
& Receptor areas), Dental Extractions
• Dosage: Apply 5 to 10 drops or sufficient quantity to cover the wound
completely.

Systemic Agents:
Ethamsylate
• Hemostatic mechanism is due to activation of thromboplastin formation on
damaged vessel walls and decrease prostacyclin 2 synthesis and facilitates
platelet aggregation.
• Ethamsylate reduces capillary bleeding in the presence of normal number of
platelets.
• It acts by correcting abnormal platelet adhesion.
• exerts antihyaluronidase action,improves capillary [Link],not stabilize
fibrin(not an antifibrinolytic)
• Indications: used in prevention and treatment of capillary bleeding in
menorrhagia, epistaxis, hematuria after tooth extraction
• Efficacy is unsubstantiated
• adverse effects like rash are common and blood pressure falls only after IV
injection.
• Dose: 250-500 mg TDS orally

Tranexamic acid
• Tranexamic acid 4.8% oral rinse is an antifibrinolytic agent that stabilizes clots
and facilitates clot formation by competitively inhibiting plasminogen, the
enzyme responsible for activating plasmin.
• It can also be useful as a prophylactic mouthwash in patients who are on
anticoagulant medications which require oral surgery.
• It can be used preoperatively, intraoperatively, or postoperatively to manage
bleeding.
• popular as a post-operative hemostatic mouthwash.

Whole Blood
• Fresh whole blood refers to blood that is administered within 24 hours of its
donation.
• Whole blood transfusion indicated when there is excessive blood loss.
©MDS Made [Link]
drpnnreddy@[Link]
 ORAL & MAXILLOFACIAL SURGERY 11
Paper – I (Physiology)

• Contains all factors for coagulation

• Must be checked for HIV, hepatitis B, C viruses.

Platelet Rich Plasma

• Platelets can be collected from donated whole blood.
• Platelet concentrates are viable for 3 days when stored at room temperature.
• Must be infused quickly via short i.v. tranfusion set
• One unit raises platelet count by approx 7,000 to 10,000 cells per cu mm.

Fresh Frozen Plasma

• Unit of fresh frozen plasma is collected from one donor and contains all
coagulation factors.
• Stored at -30°C
• should be infused within 2 hours once defrosted.

Cryoprecipitate
• Stored at -30°C.
• Each bag is derived from single donor and is not treated to inactivate viruses.
• Associated with a substantial risk of viral transmission.

Thermal agents
Heat achieves hemostasis by denaturation of proteins.
Cautery
• Heat is transmitted from instrument by conduction directly to the tissues.
• Electrocautery has replaced direct heat application.
• Dental burnisher like instrument can be directly heated over flame and applied
directly to the bleeding point.

Electrocautery
• Most widely used.
• Electrocautery can be applied directly to bleeding point.
• Cautery point is touched to the hemostat, causing sealing of vessel through
action of heat
• Causes tissue destruction producing burning smell and smoke during
application
• Advantages
©MDS Made [Link]
drpnnreddy@[Link]
 ORAL & MAXILLOFACIAL SURGERY 12
Paper – I (Physiology)

o Permits any degree of hemorrhage control.

o Provides clear and improved view.
o Increases efficiency.
o Reduces chair side time.
o Gives pressureless cutting.

Cryosurgery
• Temperature ranging from -20°C to -180°C are used.
• Tissues, capillaries, small arterioles and venules undergo cryogenic necrosis.
• Caused by dehydration and denaturation of lipid molecules.
• specially used to treat superficial hemangiomas.

Lasers
• Lasers usually result in bloodless surgery.
• Effectively coagulate the small blood vessels during cutting of tissues.

REFERENCES

1. Malik NA, Textbook of oral and maxillofacial surgery. 3rd Ed. (2012). New Delhi
: Jaypee Brothers Medical Publishers (P) Ltd.
2. Shenoy A, Shenoy R. Manipal manual of Surgery, 4 th Edition. 2014. CBS
Publishers & Distributors
3. Peterson. Peterson's Principles of Oral and Maxillofacial Surgery. Shelton, CT:
People's Medical Pub. House-USA, 2012.
4. Behrens AM, Sikorski MJ, Kofinas P. Hemostatic strategies for traumatic and
surgical bleeding. J Biomed Mater Res A. 2014; 102 (11): 4182–4194.
5. McBee WL, Koerner KR. Review of hemostatic agents used in dentistry. Dent
Today. 2005; 24 (3): 62-5

©MDS Made [Link]

drpnnreddy@[Link]