What is the best course of action for a pediatric patient with unexplained gum bleeding?

Unexplained Gum Bleeding in Pediatric Patients

For a pediatric patient with unexplained gum bleeding, immediately assess for dental trauma history and examine for signs of gingivitis (plaque accumulation, gingival swelling, erythema), then systematically rule out bleeding disorders if no local cause is identified.

Initial Assessment and Most Common Causes

Examine for Gingivitis First

• Plaque-induced gingivitis is the most common cause of gum bleeding in children and presents with gingival redness, swelling, and bleeding on probing or brushing, typically without spontaneous bleeding. 1
• Poor oral hygiene leads to bacterial plaque biofilm accumulation, which is the primary etiology in pediatric patients aged 3-7 years. 1
• Children may be asymptomatic or unaware of the disease, as gingivitis is usually painless and rarely causes spontaneous bleeding. 1
• Infants and toddlers are particularly susceptible during the teething period (4-7 months onward) when oral hygiene is often overlooked, making infectious gingivitis a critical consideration even in very young children. 2

Obtain Targeted History

• Ask about oral hygiene practices: frequency of tooth brushing, use of fluoride toothpaste, and when oral hygiene routines were established. 2, 1
• Determine frequency of dental visits and whether the child has an established dental home (recommended within 6 months of first tooth eruption). 3
• Inquire about recent dental trauma, even minor injuries, as post-traumatic complications can present with gum bleeding weeks later. 4, 5
• Assess dietary habits, particularly sugar intake and frequency of snacking, as these correlate with gingivitis prevalence. 1
• Document any history of easy bruising, prolonged bleeding from minor cuts, epistaxis, or family history of bleeding disorders. 6

Physical Examination Findings to Guide Diagnosis

Signs Indicating Gingivitis

• Gingival tissue appears swollen, erythematous, and bleeds easily with gentle probing or brushing. 1, 7
• Visible plaque accumulation on tooth surfaces, particularly at the gingival margin. 1
• Positive correlation exists between dental caries (dmft/DMFT > 0) and gingivitis occurrence, so examine for cavitated lesions. 1

Red Flags Requiring Immediate Dental Referral

• Extensive gingival or facial swelling suggests potential abscess formation requiring same-day dental evaluation. 5, 8
• Parulis (gum boil) appearing on gingiva adjacent to a tooth indicates pulpal necrosis and potential periapical abscess. 4, 8
• Gray tooth discoloration after trauma signals pulpal hemorrhage and potential necrosis. 5, 8
• Multiple teeth moving together when palpated may indicate alveolar bone fracture. 5, 8
• Increased tooth mobility with gingival swelling suggests pulpal necrosis with periapical involvement. 4, 8

Signs Suggesting Bleeding Disorder

• If gingival bleeding is spontaneous, excessive, or disproportionate to the degree of local inflammation, consider systemic bleeding disorders. 6
• Look for petechiae, ecchymoses, or other signs of bleeding diathesis on physical examination. 6
• Bleeding from multiple sites (not just gingiva) or bleeding that is difficult to control with local measures warrants hematologic evaluation. 6

Management Algorithm

For Gingivitis (Most Common Scenario)

• Educate caregivers on proper oral hygiene: brush teeth twice daily with fluoride toothpaste, starting from the eruption of the first tooth. 2, 7
• Recommend establishing a dental home if not already done, with routine preventive visits every 6 months. 3, 7
• Provide dietary counseling to reduce sugar intake and frequency of snacking. 1, 7
• For established gingivitis with significant plaque accumulation, consider professional dental cleaning and possible short-term antibiotic therapy if infectious component is severe. 2
• Gingivitis is reversible with improved oral hygiene and typically resolves within 1-2 weeks of proper tooth brushing. 1, 7

For Post-Traumatic Gum Bleeding

• Refer to pediatric dentist within days (not immediate) if gray tooth discoloration develops after trauma. 5, 8
• Provide post-injury care instructions: soft diet for 10 days, restrict pacifier/thumb sucking, maintain gentle oral hygiene. 4, 5
• Educate caregivers to monitor for signs of pulpal necrosis: gingival swelling, parulis, increased mobility, or tooth discoloration. 4, 5
• Children may not report pain from necrotic teeth, so visual monitoring by caregivers is essential. 4, 8

For Suspected Bleeding Disorder

• If no local cause is identified and bleeding is excessive or spontaneous, obtain complete blood count with platelet count, prothrombin time, and activated partial thromboplastin time. 6
• Consider referral to pediatric hematology if initial screening suggests coagulopathy. 6
• One case report documented a 13-month-old with "gushing gums" and worsening anemia who underwent extensive hematologic workup before infectious gingivitis was diagnosed—highlighting the importance of considering local causes first. 2

Common Pitfalls to Avoid

• Do not immediately pursue extensive hematologic workup without first examining for local causes like gingivitis or dental trauma, as this leads to unnecessary testing and specialist referrals. 2
• Do not assume young infants and toddlers are too young for gingivitis—bacterial buildup can occur as soon as teeth erupt. 2
• Never overlook the possibility of child abuse in children younger than 5 years with oral trauma, particularly if mechanism is inconsistent with developmental stage. 5, 8
• Do not rely on pain complaints to identify dental pathology in children, as they often do not report discomfort from necrotic teeth. 4, 8
• Avoid probing to the bottom of the pocket when assessing for gingivitis in young children, as this is a poor indicator of early disease; instead, probe the marginal gingiva gently. 9

When Antibiotics Are Not Indicated

• Routine systemic antibiotics are not indicated for uncomplicated gingivitis or post-traumatic dental injuries unless specific medical conditions require coverage. 4, 5
• Antibiotics should be reserved for severe infectious gingivitis with systemic signs or when there is evidence of abscess formation. 2