From the Guidelines
Bleeding gums in patients with end-stage liver disease are primarily caused by coagulation abnormalities, thrombocytopenia, and other factors such as portal hypertensive gastropathy, malnutrition, poor oral hygiene, and medications. The liver normally produces factors II, V, VII, IX, and X, and when liver function deteriorates, these factors become deficient, leading to increased bleeding tendency 1. Thrombocytopenia (low platelet count) is another common cause, resulting from portal hypertension and subsequent splenic sequestration of platelets, with mechanisms including reduced production, increased destruction, and possible sequestration in the spleen 1. Additionally, patients may develop portal hypertensive gastropathy that can extend to the oral mucosa, causing fragile blood vessels prone to bleeding. Malnutrition, common in liver disease, can lead to vitamin K deficiency, further impairing clotting 1. Poor oral hygiene, which is often neglected in seriously ill patients, can cause gingivitis that exacerbates bleeding. Medications like aspirin, NSAIDs, or anticoagulants that patients might be taking for comorbidities can increase bleeding risk. Management should include gentle oral care with soft toothbrushes, treating underlying coagulopathy with vitamin K (10mg daily for 3 days) or fresh frozen plasma if needed, addressing thrombocytopenia if severe (platelet count <10,000), and consulting with dental professionals familiar with liver disease patients. It is essential to consider the "rebalanced" hemostatic state in patients with liver disease, where both pro- and anti-haemostatic systems change simultaneously, and traditional coagulation tests may not accurately predict bleeding risk 1. Viscoelastic tests of coagulation, such as thromboelastography (TEG) or rotational thromboelastometry (ROTEM), may provide more insight into the hemostatic status of these patients, but their role in predicting post-procedural bleeding is still being explored 1. In clinical practice, the absence of high-quality clinical studies and the limited understanding of the hemostatic changes in liver disease pose challenges in managing bleeding and thrombosis in these patients 1. Therefore, a comprehensive approach, considering the patient's overall condition, underlying liver disease, and potential comorbidities, is necessary to manage bleeding gums in patients with end-stage liver disease.
From the Research
Possible Causes of Bleeding Gums
- Coagulopathy associated with end-stage liver disease, which results from a complex derangement in both anticoagulant and procoagulant processes 2
- Rebalanced coagulation profile, leading to a risk of both excessive clotting and bleeding 3
- Endothelial dysfunction, which likely plays a central role in hypercoagulability 4
- Thrombocytopenia, which can increase the risk of bleeding 5
- Elevated international normalized ratio (INR), which can indicate a higher risk of bleeding 6, 5
Factors Contributing to Bleeding Risk
- Severity of liver disease, with more severe disease associated with a higher risk of bleeding 5
- Platelet count, with lower counts associated with a higher risk of bleeding 5
- INR, with higher values associated with a higher risk of bleeding 6, 5
- Presence of other medical conditions, such as nonalcoholic steatohepatitis or autoimmune conditions, which can increase the risk of thrombotic events 4
Assessment and Management of Coagulopathy
- Viscoelastic coagulation tests, such as thromboelastography and rotational thromboelastometry, can provide a dynamic assessment of clot formation and help guide management of coagulation problems 2, 3
- Targeted transfusion protocols and pharmacologic prevention of fibrinolysis may aid in the management of coagulopathy 2
- Thrombosis prophylaxis should be considered in susceptible populations, such as patients with end-stage liver disease 3, 4