I just saw a patient who had an extraction 5 days ago. The patient is 63 yrs old and on coumadin. Bleeding started last night. When I saw that she had a clot hanging out of the socket, yet it was firm like their was a hard sack around coagulated blood - it looked just like this picture from hemophilia.org
This is a "liver clot" or a malformed clot which prevents proper clotting and healing. These should be carefully removed to allow for proper hemostasis and healing. Below is an excellent video from onlineoralsurgery.com that demonstrates the process:
1. Have the patient rinse with a 5% solution of Transexamic Acid for hemostatis (optional)
2. Give local anesthetic with epinephrine for vasoconstriction
3. Gently remove the liver clot
4. obtain hemostatis (gel foam, suture, gauze compression dressing, tissue glue)
