What causes severe gum bleeding leading to anemia in a healthy individual?

Severe Gum Bleeding Causing Anemia in Otherwise Healthy Individuals

In a truly healthy individual without systemic disease, isolated severe gum bleeding causing anemia is almost always due to local periodontal disease, but you must systematically rule out occult hematologic disorders (particularly immune thrombocytopenic purpura, aplastic anemia, and acquired hemophilia), medication effects (especially anticoagulants, antiplatelets, and NSAIDs), and hereditary hemorrhagic telangiectasia before attributing it solely to dental pathology.

Initial Diagnostic Approach

Rule Out Medication-Related Causes First

• Immediately assess for anticoagulant or antiplatelet use (warfarin, DOACs, aspirin, clopidogrel, NSAIDs), as these are common culprits that can transform minor gingival inflammation into severe bleeding 1
• Determine if dosing is appropriate and consider temporarily discontinuing these agents if bleeding is severe enough to cause anemia 1
• NSAIDs are particularly important to identify and stop, as they commonly contribute to occult bleeding 1

Assess Bleeding Severity and Hemodynamic Status

• Check hemoglobin level immediately - a drop ≥2 g/dL requiring ≥2 units RBCs defines major bleeding 2
• Evaluate for hemodynamic instability: tachycardia, systolic BP <90 mmHg, or orthostatic changes (systolic drop ≥20 mmHg or diastolic drop ≥10 mmHg) 1
• If hemoglobin is <7 g/dL or patient is symptomatic, transfuse RBCs to maintain ≥7 g/dL (or ≥8 g/dL if coronary disease present) 2

Essential Laboratory Workup

Hematologic Screening

• Complete blood count with differential - look for thrombocytopenia, leukopenia, or pancytopenia 3, 4
• Serum ferritin (<12 μg/dL is diagnostic of iron deficiency; the most powerful test for iron deficiency) 1
• Platelet count - even "normal" platelet counts (>150,000/μL) do not exclude immune thrombocytopenic purpura if there is unexplained bleeding 5
• Coagulation studies (PT/INR, aPTT) to screen for acquired hemophilia or other coagulopathies 1

Critical Pitfall

Do not assume normal platelet counts exclude ITP - spontaneous gingival bleeding can be the sole manifestation of ITP even with platelet counts within normal range, as platelet dysfunction rather than quantity may be the issue 5

Specific Conditions to Consider

Hematologic Disorders Presenting as Isolated Gum Bleeding

Aplastic Anemia:

• Presents with spontaneous gingival bleeding, fatigue, and increased bruising due to pancytopenia 3, 4
• Platelet counts typically <10,000/μL in severe cases 3
• Requires platelet transfusion to >25,000/μL before any dental intervention 3

Immune Thrombocytopenic Purpura (ITP):

• Can present with unprovoked periodontal hemorrhage as the only manifestation 5
• May occur with platelet counts >150,000/μL (platelet dysfunction rather than thrombocytopenia) 5
• Requires medical intervention to correct hemostasis before local dental measures will work 5

Acquired Hemophilia A:

• Presents with subcutaneous bleeding and mucosal bleeding including gums 1
• Diagnosed by prolonged aPTT and factor VIII inhibitor assay 1

Hereditary Hemorrhagic Telangiectasia (HHT)

• Consider HHT if there is recurrent epistaxis in addition to gum bleeding 1
• Mucosal telangiectasias cause chronic bleeding leading to severe iron-deficiency anemia 1
• Systemic bevacizumab (5 mg/kg IV every 2 weeks for 4-6 doses, then maintenance) is recommended for moderate-to-severe bleeding unresponsive to local measures 1
• Oral tranexamic acid (500 mg twice daily, increasing to 1000 mg four times daily) is first-line for mild bleeding 1

Infectious Causes

Malaria (Plasmodium falciparum):

• Acute severe gingival bleeding can be the presenting sign of falciparum malaria 6
• Medical treatment of underlying infection is necessary before local dental measures will control bleeding 6

Local Periodontal Disease as Primary Cause

When to Attribute Bleeding to Periodontal Disease Alone

• Only after excluding systemic causes above 7
• Chronic severe periodontitis can cause mild anemia (lower hemoglobin, hematocrit, and RBC count compared to controls), but this is typically mild and not transfusion-requiring 7
• If anemia is severe enough to require transfusion, strongly suspect an underlying hematologic disorder even if periodontal disease is present 3, 5, 4

Management of Periodontal Bleeding in Hematologically Compromised Patients

• Coordinate with hematology - platelet transfusion to >25,000/μL is required before subgingival scaling 3
• Use local minocycline chemotherapy when neutrophil count <2,000/μL 3
• Nonsurgical therapy (scaling, local drug delivery) followed by electrosurgery for residual gingival enlargement 4
• Medical correction of underlying hemostatic defect is mandatory before local dental measures will succeed 5, 6

Management Algorithm

Step 1: Immediate Stabilization

• Transfuse RBCs if hemoglobin <7 g/dL or patient symptomatic 2
• Apply firm sustained compression to bleeding gingival sites for ≥5 minutes 1
• Temporarily discontinue anticoagulants/antiplatelets if present 1, 2

Step 2: Identify Underlying Cause

• Complete hematologic workup as outlined above
• Assess for medication effects (anticoagulants, antiplatelets, NSAIDs) 1
• Screen for HHT (recurrent epistaxis, family history, mucosal telangiectasias) 1
• Consider infectious causes if acute presentation (malaria in endemic areas) 6

Step 3: Treat Underlying Condition

• Hematologic disorders require medical management first - local dental measures will fail without correcting the systemic hemostatic defect 5, 6
• For HHT: tranexamic acid for mild bleeding, systemic bevacizumab for moderate-to-severe bleeding 1
• For aplastic anemia/ITP: coordinate with hematology for platelet support and immunosuppression 3, 4

Step 4: Definitive Periodontal Treatment

• Only proceed after systemic stabilization 3, 5, 4
• Ensure adequate platelet count (>25,000/μL) before invasive procedures 3
• Use antibiotic prophylaxis if neutropenic 3

Key Takeaway

The critical error is assuming severe gum bleeding causing anemia is "just" periodontal disease without systematic exclusion of hematologic disorders, medications, and HHT - these conditions require medical intervention before local dental treatment will be effective, and missing them can be life-threatening 5, 6.