Gum bleeding
Bleeding gums, or gingival bleeding, usually result from dental disorders; less commonly, they may stem from a blood dyscrasia or the effects of certain drugs. Physiologic causes of this common sign include pregnancy, which can produce gum swelling in the first or second trimester (pregnancy epulis); atmospheric pressure changes, which usually affect divers and aviators; and oral trauma. Bleeding ranges from slight oozing to life-threatening hemorrhage. It may be spontaneous or may follow trauma. Occasionally, direct pressure can control it.
Emergency Actions
If you detect profuse, spontaneous bleeding in the oral cavity, quickly check airway patency and look for signs of cardiovascular collapse, such as tachycardia and hypotension. Suction the patient. Apply direct pressure to the bleeding site. Expect to insert an airway, administer I.V. fluids, and collect serum samples for diagnostic evaluation.
History
If gum bleeding isn’t an emergency, obtain a history. Find out when the bleeding began. Has it been continuous or intermittent? Does it occur spontaneously or when the patient brushes his teeth or flosses? Have the patient show you the site of the bleeding, if possible.
Find out if the patient or any family members have bleeding tendencies; for example, ask about easy bruising and frequent nosebleeds. How much does the patient bleed after a tooth extraction? Does he have a history of liver or spleen disease? Next, check the patient’s dental history. Find out how often he brushes his teeth, flosses, and goes to the dentist. Also ask the patient what kind of toothbrush and floss he uses. Has he seen a dentist recently? To evaluate nutritional status, have the patient describe his normal diet and intake of alcohol. Finally, note any prescription and over-the-counter drugs he takes.
Physical assessment
Perform a complete oral examination. If the patient wears dentures, have him remove them. Examine the gums to determine the site and amount of bleeding. Gums normally appear pink and rippled with their margins snugly against the teeth. Check for inflammation, pockets around the teeth, swelling, retraction, hypertrophy, discoloration, and gum hyperplasia. Note obvious decay, discoloration, foreign material such as food, and the absence of any teeth.
Medical causes
Agranulocytosis
Spontaneous gum bleeding and other systemic hemorrhages may occur in agranulocytosis, a hematologic disorder that typically causes progressive fatigue and weakness. Bleeding may be followed by signs of infection, such as fever and chills. Inspection may reveal oral and perianal lesions, which are usually rough edged with a gray or black membrane.
Aplastic anemia
In aplastic anemia, profuse or scant gum bleeding may follow trauma. Other signs of bleeding, such as epistaxis and ecchymoses, are also characteristic. The patient exhibits progressive weakness and fatigue, shortness of breath, headache, pallor and, possibly, fever. Eventually, tachycardia and signs of heart failure, such as jugular vein distention and dyspnea, also develop.
Cirrhosis
A late sign of cirrhosis, gum bleeding occurs with epistaxis and other bleeding tendencies. Additional late effects include ascites, hepatomegaly, pruritus, and jaundice. Other signs and symptoms include abdominal pain, anorexia, fatigue, nausea, vomiting, and weakness.
Gingivitis
Reddened and edematous gums are characteristic of gingivitis. The gingivae between the teeth become bulbous and bleed easily with slight trauma. However, with acute necrotizing ulcerative gingivitis, bleeding is spontaneous and the gums become so painful that the patient may be unable to eat. A characteristic grayish yellow pseudomembrane develops over punched-out gum erosions. Offensive halitosis is typical and may be accompanied by headache, malaise, fever, and cervical adenopathy.
Hemophilia
In hemophilia, hemorrhage occurs from many sites in the oral cavity, especially the gums. Mild hemophilia causes easy bruising, hematomas, epistaxis, bleeding gums, and prolonged bleeding during even minor surgery and up to 8 days afterward. Moderate hemophilia produces more frequent episodes of abnormal bleeding and occasional bleeding into the joints, which may cause swelling and pain. Severe hemophilia causes spontaneous or severe bleeding after minor trauma, possibly resulting in large subcutaneous and intramuscular hematomas. Bleeding into joints and muscles causes pain, swelling, and extreme tenderness and may cause permanent deformity. Bleeding near peripheral nerves causes peripheral neuropathies, pain, paresthesia, and muscle atrophy. Signs of anemia and fever may follow bleeding. Severe blood loss may lead to shock and death.
Leukemia
Easy gum bleeding is an early sign of acute monocytic, lymphocytic, or myelocytic leukemia that’s accompanied by gum swelling, necrosis, and petechiae. The soft, tender gums appear glossy and bluish. Acute leukemia causes severe prostration marked by high fever and bleeding tendencies, such as epistaxis and prolonged menses. It may also cause dyspnea, tachycardia, palpitations, and abdominal or bone pain. Later effects may include confusion, headaches, vomiting, seizures, papilledema, and nuchal rigidity.
Chronic leukemia usually develops insidiously, producing less-severe bleeding tendencies. Other effects may include anorexia, weight loss, low-grade fever, chills, skin eruptions, and enlarged spleen, tonsils, and lymph nodes. Signs of anemia, such as fatigue and pallor, may also occur.
Periodontal disease
Gum bleeding typically occurs after chewing, toothbrushing, or gum probing but may also occur spontaneously. As gingivae separate from the bone, pus-filled pockets develop around the teeth; occasionally, pus can be expressed. Other findings include unpleasant taste with halitosis, facial pain, loose teeth, and dental calculi and plaque.
Pernicious anemia
Gum bleeding and a sore tongue make eating painful for patients with pernicious anemia. Among other cardinal symptoms are weakness and paresthesia. The patient’s lips, gums, and tongue appear markedly pale, and his sclera and skin are jaundiced. Other features are typically widespread, affecting the GI, cardiovascular, and central nervous systems, and include altered bowel and bladder habits, personality changes, ataxia, tinnitus, dyspnea, and tachycardia.
Polycythemia vera
In polycythemia vera, engorged gums ooze blood after even slight trauma. Polycythemia vera usually turns the oral mucosa — especially the gums and tongue — a deep red-violet. Among associated findings are headache, dyspnea, dizziness, fatigue, paresthesia, tinnitus, double or blurred vision, aquagenic pruritus, epigastric distress, weight loss, increased blood pressure, ruddy cyanosis, ecchymosis, and hepatosplenomegaly.
Thrombocytopenia
With thrombocytopenia, blood usually oozes between the teeth and gums; however, severe bleeding may follow minor trauma. Associated signs of hemorrhage include large blood-filled bullae in the mouth, petechiae, ecchymosis, epistaxis, and hematuria. Malaise, fatigue, weakness, and lethargy eventually develop.
Thrombocytopenic purpura (idiopathic)
Profuse gum bleeding occurs in idiopathic thrombocytopenic purpura. Its classic feature, though, is spontaneous hemorrhagic skin lesions that range from pinpoint petechiae to massive hemorrhages. The patient has a tendency to bruise easily, develops petechiae on the oral mucosa, and may exhibit melena, epistaxis, or hematuria.
Vitamin K deficiency
The first sign of vitamin K deficiency is usually gums that bleed when the teeth are brushed. Other signs of abnormal bleeding, such as ecchymosis, epistaxis, and hematuria, may also occur. GI bleeding may produce hematemesis and melena; intracranial bleeding may cause decreased level of consciousness and focal neurologic deficits.
Other causes
Chemical irritants
Occupational exposure to benzene may irritate the gums, resulting in bleeding. Other signs of abnormal bleeding may accompany limb weakness and sensory changes.
Drugs
Warfarin and heparin interfere with blood clotting and may cause prolonged gum bleeding. Abuse of aspirin and nonsteroidal anti-inflammatory drugs may alter platelets, producing bleeding gums. Localized gum bleeding may also occur with mucosal “aspirin burn” caused by dissolving aspirin near an aching tooth.
Special considerations
Prepare the patient for diagnostic tests, such as blood studies or facial X-rays. Prepare him for the possibility of a blood or blood product (platelets or fresh frozen plasma) transfusion, if necessary. When providing mouth care, avoid using lemon-glycerin swabs, which may burn or dry the gums.
Pediatric pointers
In neonates, bleeding gums may result from vitamin K deficiency associated with a lack of normal intestinal flora or poor maternal nutrition. In infants who primarily drink cow’s milk and don’t receive vitamin supplements, bleeding gums can result from vitamin C deficiency.
Encourage parents to teach proper oral hygiene early. Daily brushing in the morning and before bedtime should begin with eruption of the first tooth. When the child has all of his baby teeth, he should begin receiving regular dental checkups.
Geriatric pointers
In patients who have no teeth, constant gum trauma and bleeding may result from using a dental prosthesis.
Patient counseling
Teach the patient proper mouth and gum care and proper brushing techniques, including use of a soft-bristled toothbrush. Encourage him to seek regular dental care. Make sure patients with chronic disorders that predispose them to bleeding, such as chronic leukemia, cirrhosis, or idiopathic thrombocytopenic purpura, are aware that bleeding gums may indicate a worsening of their condition, requiring immediate medical attention.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Bleeding gums
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- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
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- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
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Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.
More About Causes of Bleeding gums
» Next page: Hemoptysis (The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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