What is the best approach to manage gum bleeding in an adult patient with a history of dental procedures and potential bleeding risks, who may be on anticoagulation (anti-coagulant) therapy?

Management of Gum Bleeding

For gum bleeding in adults, continue anticoagulation therapy while applying local hemostatic measures, as gum bleeding is classified as non-major and does not warrant interruption of anticoagulants. 1

Initial Assessment

Determine bleeding severity using the American College of Cardiology criteria for major bleeding 2, 1:

• Hemodynamic instability (hypotension, tachycardia)
• Hemoglobin decrease ≥2 g/dL from baseline
• Need for ≥2 units of red blood cell transfusion
• Bleeding at a critical site

Gum bleeding after dental procedures typically does not meet these criteria and is classified as non-major bleeding. 1

Management Strategy for Non-Major Gum Bleeding

Continue Anticoagulation

• Do not stop oral anticoagulants (warfarin, DOACs, or antiplatelet agents) for routine gum bleeding. 1, 3
• Continuing DOAC therapy during low-to-moderate risk dental procedures results in low bleeding rates that are easily controlled with local measures. 3
• Interrupting anticoagulation significantly increases thromboembolic risk without meaningful reduction in bleeding complications. 1

Local Hemostatic Measures

Apply the following measures in sequence 1, 4:

• Clean the bleeding site with sterile saline
• Apply gauze soaked in tranexamic acid directly to bleeding gums with gentle manual compression for 3-5 minutes 1, 4
• Tranexamic acid-soaked gauze improves hemostasis by a factor of 1.6 compared to compression alone 4
• Prescribe tranexamic acid mouthwash 2-3 times daily for 1-2 days post-procedure 1

Tranexamic acid is FDA-approved for reducing hemorrhage during and following tooth extraction in patients with hemophilia, and is effective as a topical hemostatic agent. 5, 4

Additional Hemostatic Options

If initial measures are insufficient 6, 7:

• Sutures for more persistent bleeding
• Native collagen fleeces or hemostatic plugs
• Hemostatic agents reduce time to achieve hemostasis and decrease postoperative bleeding events (risk ratio 0.62) 7

Critical Pitfalls to Avoid

• Never bridge with heparin or interrupt anticoagulation for routine dental-related bleeding - this significantly increases both bleeding risk and thromboembolic risk. 1
• Do not administer reversal agents (protamine, vitamin K, prothrombin complex concentrates, idarucizumab, andexanet alfa) for simple gum bleeding - these are reserved exclusively for life-threatening hemorrhage. 1, 2
• Avoid low-molecular-weight heparin in the immediate postoperative period as it predisposes to hematoma formation. 8

When to Escalate Care

Stop anticoagulation and escalate management only if 2, 1:

• Bleeding becomes uncontrollable with local measures
• Patient develops hemodynamic instability
• Hemoglobin drops ≥2 g/dL
• Bleeding extends to involve critical sites (intracranial, intraspinal, intraocular, pericardial, intra-articular, intramuscular with compartment syndrome, or retroperitoneal) 2

For major bleeding, stop oral anticoagulants immediately, provide supportive care with volume resuscitation, and administer reversal/hemostatic agents (vitamin K 5-10 mg IV for warfarin, prothrombin complex concentrates, or specific DOAC reversal agents). 2

Special Considerations

• Patients with poor gingival health or extensive periodontal disease may require more aggressive local measures, but anticoagulation should still be continued unless bleeding becomes major. 1
• Most bleeding from dental surgery can be controlled by pressure alone; hemostatic agents are used when pressure does not yield satisfactory results. 6
• Documented bleeding in patients continuing DOACs during dental procedures is mild and easily controlled by local hemostatic measures. 3