What is the best approach to manage bleeding gums?

Management of Bleeding Gums

The most effective approach to manage bleeding gums is professional dental cleaning (scaling and root planing) combined with proper mechanical plaque removal through twice-daily toothbrushing and daily interdental cleaning, supplemented with antimicrobial mouthwash when indicated. 1, 2

Initial Assessment

Determine the severity and underlying cause of gingival bleeding:

• Localized gingivitis presents with bleeding during brushing, visible plaque and calculus, but no tooth mobility—this represents reversible inflammation that has not progressed to periodontitis 1
• Assess for systemic factors that may contribute to bleeding, including anticoagulant use, thrombocytopenia, uremia, or liver disease 3
• Rule out major bleeding by evaluating for hemodynamic instability, bleeding at critical sites, or hemoglobin decrease ≥2 g/dL 3

Primary Treatment: Mechanical Plaque Removal

Professional Intervention

• Professional scaling and root planing with polishing is essential as the first step, since calculus cannot be removed by regular brushing alone 1, 2
• This should be performed by a dental professional before initiating home care regimens 1

Home Oral Hygiene Protocol

Toothbrushing technique:

• Use a small, soft-bristled toothbrush at least twice daily for minimum 2 minutes 1
• Ensure the gingival portion of the tooth and periodontal sulcus are included in brushing 1
• Critical pitfall: Bleeding is a sign of inflammation, not a reason to avoid brushing—patients must continue mechanical cleaning despite initial bleeding 1

Interdental cleaning:

• Daily flossing is essential for removing interproximal plaque 1, 4
• Interdental brushes may be more effective than floss for reducing gingivitis and plaque, particularly in accessible interdental spaces 4, 5
• Proper flossing technique using an adapted horizontal-vertical flossing technique can reduce interproximal bleeding by 70% at 8 weeks 6
• Consider plaque-disclosing agents to improve visualization and removal 1

Adjunctive Chemical Plaque Control

Chlorhexidine Mouthwash (First-Line Antimicrobial)

• 0.12-0.2% chlorhexidine gluconate used twice daily for 60 seconds is FDA-approved for gingivitis treatment 2, 7
• Critical timing: Wait 30 minutes after toothbrushing before using chlorhexidine, as toothpaste ingredients may inactivate it 2
• Limitations: May cause tooth staining, taste alteration, and increased calculus formation with prolonged use 8, 2

Natural Product-Based Alternatives

When chlorhexidine side effects are problematic or for long-term maintenance, evidence-based natural alternatives include:

• Green tea mouthwash (1-5%) demonstrates similar anti-plaque and anti-gingivitis effects to chlorhexidine 8
• Lemongrass oil (0.25%) used twice daily for 1 minute shows comparable results to chlorhexidine 8, 2
• Aloe vera (100%) used twice daily for 1 minute reduces plaque and gingival inflammation 8, 2
• Turmeric (0.1%) mouthwash demonstrates effectiveness similar to chlorhexidine 8, 2
• Triphala mouthwash (10mL twice daily) is cost-effective with no reported side effects 2

The advantage of natural alternatives is the absence of tooth staining while maintaining comparable anti-plaque and anti-inflammatory effects 2

Treatment Algorithm

1. Perform professional dental cleaning to remove existing plaque and calculus 1, 2
2. Educate on proper mechanical plaque removal (brushing technique and interdental cleaning) 2, 9
3. Add antimicrobial mouthwash (chlorhexidine or natural alternative) as adjunctive therapy 2, 7
4. Reassess gingival health after 2-4 weeks to adjust treatment plan 8, 2
5. Schedule regular dental check-ups every 6 months to monitor for reduction in gingival bleeding, plaque accumulation, and improved gingival appearance 1

When Antibiotics Are NOT Indicated

• Antibiotics are generally not recommended for routine gingivitis treatment 2
• Consider antibiotics only if systemic involvement exists (fever, malaise, lymphadenopathy) or infection extends into facial spaces 2
• When necessary, amoxicillin is first choice, with amoxicillin-clavulanic acid as second option 2

Common Pitfalls to Avoid

• Do not rely solely on mouthwash—mechanical plaque removal through brushing and interdental cleaning is primary 1
• Do not discontinue treatment prematurely before complete resolution of inflammation 2
• Do not use traditional tooth powders or abrasive methods, as these cause increased gingival bleeding, recession, and tooth wear 10
• Do not ignore persistent bleeding—if bleeding continues despite proper home care after 2-4 weeks, reassessment is mandatory 8, 2