Sir, the following case of interest was seen at the dental school of the University of the West Indies, Trinidad.

A 69-year-old female patient of Afro-Caribbean descent was referred to the dental school by her general dental practitioner (GDP) with a haematoma and prolonged bleeding following routine root canal therapy (RCT). The GDP observed prolonged bleeding from the canal of the upper left second premolar (#25) subsequent to instrumentation, to the corrected working length radiograph, during RCT. The bleeding persisted longer than five minutes. Haemostasis was achieved with Haemodent followed by closure of the access with Cavit. However, a haematoma formed which involved the maxillary sinus, fascial spaces of the head and neck on the left side including the buccal and submandibular spaces and the upper part of the neck. The patient's condition was stabilised in hospital before she was referred to the dental school for further management. Her medical history revealed she had angina and 90% arterial sclerosis. She was taking antihypertensives, statins, anticoagulants, Plavix and aspirin tablets.

Extra-oral examination revealed there was a resolving haematoma (Fig. 3). Intra-orally #25 had a temporary restoration. There was mild tenderness in the buccal sulcus of the tooth. The patient was taken off Plavix, the tooth was re-accessed to the apex and a definitive restoration was placed in the tooth.

Figure 1
figure 1

The haematoma in question

Full size image

Plavix (clopidogrel) is an antiplatelet drug which reduces the risk of arterial thrombi but inevitably increases the bleeding time considerably. Haematomas and bruising are a recognised side effect. It is suspected that root canal preparation to the apex of the tooth led to periapical bleeding, exacerbated by Plavix. The manufacturer's information leaflet supplied in each pack of tablets emphasises that dentists need to be aware of this medication.

Similar incidents may occur when performing routine treatment in patients taking anticoagulants. Therefore, care should be taken by dentists to ensure each patient's full medical history is obtained. Uncontrolled bleeding has been reported during endodontic treatment in a patient with Von Willebrand's disease.1

Trinidad and Tobago