What is the differential diagnosis for a patient presenting with gingivorrhagia?

Differential Diagnosis of Gingivorrhagia

Gingivorrhagia (gingival bleeding) requires systematic evaluation beginning with assessment of local periodontal factors, followed by consideration of systemic hematologic disorders, medication effects, and rare genetic syndromes.

Primary Local Causes

Plaque-Induced Gingivitis

• Dental plaque biofilm accumulation is the most common cause of gingival bleeding, with microbial species including Streptococcus, Fusobacterium, Actinomyces, Veillonella, and Treponema triggering inflammatory responses 1
• Clinical gingival health is defined by absence of bleeding on probing; presence of bleeding indicates inflammation 2
• Poor oral hygiene leads to sequential microbial colonization with increasing flora complexity over time 1

Periodontal Disease

• Established gingivitis can progress to periodontitis with attachment loss and alveolar bone destruction 1
• Patients with periodontal disease history have increased risk of periodontal abscesses with rapid tissue destruction 3
• Clinical signs include gingival swelling, increased tooth mobility, and sinus tract formation 4

Periapical Pathology

• Failed endodontic treatment with persistent infection can present with gingival swelling and bleeding 3
• Periapical abscess or granuloma may manifest as gingival changes above tooth apex 3
• If fistula is present, obtain intraoral radiograph with gutta-percha cone inserted to identify source 3, 5

Desquamative Gingivitis Conditions

Autoimmune Mucocutaneous Diseases

• Oral lichen planus, cicatricial pemphigoid, and pemphigus vulgaris are the most common causes of desquamative gingivitis with associated bleeding 6
• These conditions present with pale, edematous mucosa with peeling/sloughing upon contact, and thick white exudates 5
• Biopsy with direct immunofluorescence is required for definitive diagnosis 6
• Poor oral hygiene secondary to desquamative gingivitis can lead to periodontitis and tooth loss 6

Systemic Autoimmune Disease

• Crohn's disease can cause esophageal and oral ulcerations 5
• Sjögren's disease presents with nonspecific edema and crepe paper-appearing tissue 5
• Lupus, mixed connective tissue disease, and dermatomyositis may have oral manifestations 5

Drug-Induced Gingival Enlargement

• Medications causing gingival overgrowth include calcium channel blockers, anticonvulsants (phenytoin), and immunosuppressants (cyclosporine) 7
• Diffuse gingival enlargement from medications can cause bleeding due to tissue friability and poor hygiene 7
• Thousands of cases have been described in literature, making this a relatively common finding 7

Hematologic and Systemic Causes

Coagulopathies

• Thrombocytopenia, platelet dysfunction, and clotting factor deficiencies manifest as spontaneous gingival bleeding 8
• Obtain complete blood count, PT/INR, and PTT to evaluate for bleeding disorders
• Anticoagulant therapy (warfarin, DOACs, antiplatelet agents) increases bleeding risk

Leukemia and Lymphoproliferative Disorders

• Acute leukemia can present with gingival infiltration and bleeding 7
• Lymphoma may involve oral tissues with associated bleeding 5
• Peripheral blood smear and bone marrow evaluation may be indicated

Rare Genetic Syndromes

Ramon Syndrome

• Homozygous ELMO2 mutations cause Ramon syndrome with repeated gingivorrhagia as a cardinal feature 8
• Associated findings include intellectual disability, seizures, jaw enlargement, gingival overgrowth, mandibular cysts, and fibrous dysplasia 8
• Patients may experience fatal bleeding episodes and pulmonary infections 8
• Consider in patients with consanguineous parents presenting with multiple congenital anomalies and recurrent gingival bleeding 8

Diagnostic Workup Algorithm

Initial Assessment

• Document bleeding pattern: spontaneous versus provoked, frequency, severity, and duration
• Examine for local factors: plaque accumulation, calculus, periodontal pockets, tooth mobility 1, 2
• Assess medication history for drugs causing gingival enlargement or coagulopathy 7
• Evaluate for systemic signs: fever, weight loss, lymphadenopathy, hepatosplenomegaly

Imaging Studies

• Periapical intraoral X-ray using paralleling technique is first-line imaging for localized dental pathology 3
• Panoramic radiography (orthopantomography) for comprehensive dental assessment 5
• If fistula present, radiograph with gutta-percha cone insertion identifies source tooth 5, 3

Laboratory Evaluation

• Complete blood count with differential to assess for leukemia, thrombocytopenia, anemia
• PT/INR and PTT for coagulation assessment
• Consider peripheral blood smear if hematologic malignancy suspected

Biopsy Indications

• Desquamative gingivitis requires biopsy with direct immunofluorescence for autoimmune disease diagnosis 6
• Gingival enlargement of unclear etiology warrants biopsy to exclude malignancy 7
• Persistent bleeding despite treatment of local factors necessitates tissue diagnosis

Critical Pitfalls to Avoid

• Do not attribute all gingival bleeding to poor oral hygiene without excluding systemic causes, particularly in patients with spontaneous bleeding or inadequate response to periodontal therapy 1, 2
• Desquamative gingivitis is a clinical finding, not a diagnosis; always pursue underlying etiology 6
• In patients with autoimmune disease history, monitor for oral manifestations that may precede systemic flares 5
• Ramon syndrome should be considered in consanguineous families with multiple affected members presenting with gingivorrhagia and developmental abnormalities 8