Emergency management of wisdom tooth extraction with acute bleeding due to a hemangioma in the mandibular

A 19-year-old male patient presented to the hospital with the complaint of "persistent bleeding after wisdom tooth extraction."
The patient reported that his lower wisdom tooth (#38) had been loose for several months, without pain, just mild discomfort. After visiting the dentist, a periapical X-ray was taken, and the diagnosis was made as "impacted tooth #38."

The patient was scheduled for the extraction of the lower third molar (#38) at a private clinic. As soon as the tooth became mobile, significant bleeding occurred. The dentist made an effort to remove the tooth from the socket quickly (within a few minutes) and immediately performed suturing to control the bleeding.
The patient was monitored and remained stable. However, three days post-extraction, bleeding reoccurred at the extraction site of tooth #38. The patient visited Hospital A, where he was managed with gauze pressure to control the bleeding and was stabilized before being discharged. On the fifth day post-extraction, bleeding recurred and was managed in the same manner. On the twelfth day post-extraction, the patient experienced a third episode of bleeding and was referred by the dentist to Hospital B for further evaluation.

At 13:30 on December 6th, the patient presented to Hospital B for evaluation. Upon examination, Dr. H. noted signs of anemia (pale skin and mucous membranes) and the presence of clot debris around the patient's mouth. The patient was ordered to undergo a complete blood count (CBC) and a panoramic X-ray.

The sign of pulsatile bleeding at the extraction site of tooth #38, synchronized with the patient's pulse, indicating the risk of rupture at the socket.

At 14:10 on the same day (December 6th), during the examination, the patient's blood test results upon admission showed moderate anemia:Red blood cells: 2.83 T/LHemoglobin: 84 g/LHematocrit: 0.256 L/L White blood cells and platelets were within normal limits.

The patient was immediately admitted for monitoring of the bleeding. However, during the night shift, the patient experienced profuse bleeding from the extraction site of tooth #38, which could not be controlled with gauze pressure. The patient showed signs of hemorrhagic shock and was promptly transferred to the emergency department, where vascular intervention and embolization were performed.

Emergency blood tests showed:Red blood cells: 1.76 T/LHemoglobin: 54 g/LHematocrit: 0.167 L/L, indicating moderate anemia. The patient was immediately treated in an emergency setting. A vascular angiogram was performed to assess the mass, revealing blood supply from multiple sources originating from the external carotid artery. Embolization was performed, which successfully stabilized the patient and alleviated the life-threatening condition.

Therefore, before proceeding with the extraction of a wisdom tooth, in addition to a thorough clinical examination, it is essential to conduct a complete and detailed X-ray assessment. This helps the dentist to better anticipate the procedure and prevent complications, especially in the case of vascular malformations in the jawbone, which may not present with clinical symptoms.