Gum bleeding [Gingival bleeding]

Bleeding gums usually result from dental disorders; less often, they may stem from blood dyscrasias 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 interventions

History and physical examination

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, and 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.

Next, 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 absence of any teeth.

Medical causes

Agranulocytosis

Spontaneous gum bleeding and other systemic hemorrhages may occur in this hematologic disorder, which typically causes progressive fatigue and weakness, 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 this disorder, profuse or scant gum bleeding may follow trauma. Other signs of bleeding, such as epistaxis and ecchymosis, 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. Other late effects include ascites, hepatomegaly, pruritus, and jaundice.

Ehlers-Danlos syndrome

In this congenital syndrome, gums bleed easily after toothbrushing. Easy bruising and other signs of abnormal bleeding are also typical. Skin is fragile and hyperelastic; joints are hyperextendible.

Giant cell epulis

This pedunculated granuloma, which occurs on the gums or alveolar process in front of the molars, is dark red and vascular, resembling a surface ulcer. Gums bleed easily with slight trauma.

Gingivitis

Reddened and edematous gums are characteristic of this disorder. 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. Halitosis is typical and may be accompanied by headache, malaise, fever, and cervical adenopathy.

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 for 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, extreme tenderness and, possibly, 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.

Hereditary hemorrhagic telangiectasia

This disorder is characterized by red to violet spiderlike hemorrhagic areas on the gums, which blanch on pressure and bleed spontaneously. These telangiectases may also occur on the lips, buccal mucosa, and palate; on the face, ears, scalp, hands, arms, and feet; and under the nails. Epistaxis commonly occurs early and is difficult to control. Hemoptysis and signs of GI bleeding may develop.

Hypofibrinogenemia

In this rare disorder, the patient has frequent, spontaneous episodes of severe gum bleeding. Hematomas, ecchymosis, and epistaxis are also common. Signs of GI bleeding (such as hematemesis) and of CNS bleeding (such as focal neurologic deficits) may also occur.

Leukemia

An early sign of acute monocytic, lymphocytic, or myelocytic leukemia, easy gum bleeding is 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 occur.

Pemphigoid (benign mucosal)

Most common in women between ages 40 and 50, this autoimmune disorder typically causes thick-walled gum lesions that rupture, desquamate, and then bleed easily. Extensive scars form with healing, and the gums remain red for months. Lesions may also develop on other parts of the oral mucosa, the conjunctivae and, less often, the skin. Secondary fibrous bands may lead to dysphagia, hoarseness, or blindness.

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 can make eating painful in this disorder whose other cardinal symptoms are weakness and paresthesia. The patient’s lips, gums, and tongue appear markedly pale, and his sclerae 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 this disorder, engorged gums ooze blood after even a slight trauma. Polycythemia vera usually turns the oral mucosa—especially the gums and tongue—a deep red-violet. Associated findings include headache, dyspnea, dizziness, fatigue, paresthesia, tinnitus, diplopia or blurred vision, aquagenic pruritus, epigastric distress, weight loss, increased blood pressure, ruddy cyanosis, ecchymosis, and hepatosplenomegaly.

Pyogenic granuloma

Commonly affecting the gums, lips, tongue, and buccal mucosa, this granuloma may ulcerate and bleed spontaneously or with slight trauma. The lesion is pedunculated with a smooth or warty surface.

Thrombasthenia (familial)

This hereditary blood platelet disorder causes spontaneous bleeding from the oral cavity, especially the gums. The patient commonly displays purpura, epistaxis, hemarthrosis, and signs of GI bleeding, such as hematemesis and melena.

Thrombocytopenia

In this disorder, 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 this disorder. 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 C deficiency (scurvy)

This deficiency causes swollen, spongy, tender gums that bleed easily. The gums between the teeth are red or purple. The teeth themselves become loose and may be surrounded by pockets filled with clotted blood. Other findings include muscle and joint pain, petechiae, ecchymosis, splinter hemorrhages in the nail beds, and ocular hemorrhages. Associated effects are anorexia, dry mouth, pallor, weakness, lethargy, insomnia, scaly skin, and psychological disturbances, such as depression or hysteria.

Vitamin K deficiency

The first sign of this 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, including proper brushing techniques using a soft-bristled toothbrush. (See Preventing bleeding gums.) 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.

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Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Gum symptoms: Introduction (review 151 causes)
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More About This Book: Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9

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