What causes bleeding gums?

Causes of Bleeding Gums

Bleeding gums are primarily caused by plaque-induced gingivitis, where bacterial biofilm accumulation triggers gingival inflammation, leading to bleeding during brushing or probing. 1, 2

Primary Etiology: Plaque-Induced Gingivitis

• Poor oral hygiene is the fundamental cause, resulting in bacterial plaque accumulation at the gingival margin that triggers an inflammatory response in the gingival tissues 1, 3
• The bacterial biofilm begins forming immediately after tooth cleaning and evolves to include more pathogenic flora when oral hygiene is neglected 1, 4
• Plaque accumulation leads to gingivitis within 2-3 weeks, with the bacterial composition shifting from predominantly Streptococcus species to Actinomyces-dominated flora as plaque ages 4
• Gingival inflammation causes thinning and ulceration of the crevicular mucosa, allowing bacterial access to increased capillary circulation and resulting in bleeding with minimal manipulation 1

Secondary Contributing Factors

Periodontal Disease Progression

• Untreated gingivitis can progress to periodontitis, where inflammation extends beyond the gingiva to cause destruction of periodontal ligament and alveolar bone 3, 5
• Periodontitis represents the destructive phase with deep pocket formation, bone resorption, and potential tooth loss if left untreated 5

Systemic and Medication-Related Causes

• Coagulation disorders including anticoagulant therapy (heparin during hemodialysis), thrombocytopenia, uremia, or liver disease can manifest as gingival bleeding 1, 2
• Drug-induced gingival enlargement from calcium channel blockers or cyclosporine (in transplant patients) predisposes to bleeding due to altered gingival architecture 1
• Platelet dysfunction in patients on dialysis contributes to increased bleeding tendency 1

Local Factors

• Dental calculus formation provides a rough surface that harbors bacteria and mechanically irritates gingival tissues 1
• Elevated salivary pH and mineral content (particularly in chronic kidney disease patients) promotes calculus precipitation, worsening gingival inflammation 1

Bacteremia and Daily Activities

• Routine daily activities cause more cumulative bacteremia than dental procedures: toothbrushing, flossing, and chewing food in patients with gingival inflammation produce transient bacteremia comparable to or exceeding that from dental procedures 1
• The magnitude and duration of bacteremia correlates more strongly with the degree of gingival inflammation and poor oral hygiene than with specific dental interventions 1
• This explains why maintaining excellent daily oral hygiene is more important than prophylactic antibiotics for preventing complications like infective endocarditis 1

Clinical Distinction: Gingivitis vs. Periodontitis

• Gingivitis presents with bleeding, redness, and swelling but without tooth mobility or attachment loss, making it completely reversible with proper treatment 2, 6, 3
• The presence of tooth mobility, deep periodontal pockets, or radiographic bone loss indicates progression to periodontitis, which involves irreversible tissue destruction 3, 5

Common Pitfall to Avoid

• Patients often avoid brushing bleeding gums, worsening the condition: bleeding is a sign of inflammation requiring more thorough (not less) mechanical plaque removal 6, 7
• Conversion from bleeding to non-bleeding sites requires consistent oral hygiene with toothbrushing and interdental cleaning, which significantly reduces inflamed connective tissue 7