Treatment of Bleeding Gums
For bleeding gums, the definitive treatment is professional scaling and root planing followed by meticulous home oral hygiene with twice-daily brushing using a soft-bristled toothbrush and adjunctive chlorhexidine mouthwash. 1
Immediate Management
Apply direct pressure to the bleeding site for at least 5 minutes using gauze or cotton to achieve initial hemostasis. 2 If bleeding persists beyond 2 minutes despite pressure, this warrants immediate evaluation for underlying systemic causes. 2
Clean the bleeding area with saline solution or tap water to remove debris and allow proper visualization of the bleeding source. 2
Systematic Assessment for Underlying Causes
Before proceeding with definitive treatment, you must evaluate for conditions that impair hemostasis:
- Anticoagulant therapy (warfarin, DOACs, antiplatelet agents) 2
- Thrombocytopenia 2
- Uremia (chronic kidney disease) 2
- Liver disease 2
- Hematologic disorders 3, 4
If the patient is on warfarin with minor gingival bleeding, continue anticoagulation while providing local hemostatic measures; consider 2-5 mg oral or IV vitamin K if bleeding is more significant. 2 For major bleeding with hemodynamic instability, stop anticoagulation temporarily and administer 5-10 mg IV vitamin K. 2
Definitive Treatment: Addressing Gingivitis
The root cause of bleeding gums in most patients is gingivitis from plaque accumulation, which requires both professional intervention and home care modification.
Professional Dental Treatment
Schedule professional scaling and root planing with polishing as the mandatory first-line intervention. 1, 5 This is essential because calculus deposits cannot be removed by home brushing alone and serve as a nidus for continued inflammation. 6, 1
Follow-up dental examinations should occur every 6 months minimum to monitor for reduction in gingival bleeding, decreased plaque accumulation, and improved gingival appearance. 2, 6, 1, 5
Home Oral Hygiene Protocol
Brushing technique: Use a small, ultra-soft-headed, rounded-end bristle toothbrush at least twice daily for a minimum of 2 minutes. 2, 6, 1, 5 Rinse the toothbrush in hot water before use to soften bristles. 2 Brush within 30 minutes after eating and before bedtime, ensuring the gingival portion of the tooth and periodontal sulcus are included. 2, 6, 1, 5 Replace the toothbrush when bristles no longer stand straight. 2
Toothpaste selection: Use prescription-strength fluoride toothpaste; spit out the foam but do not rinse the mouth to maximize fluoride contact. 2, 6
Flossing: Floss at least once daily, preferably using waxed floss to minimize gingival trauma. 2, 6 If flossing causes bleeding that persists beyond 2 minutes, contact your healthcare team immediately. 2, 6
Oral rinsing: Rinse vigorously several times daily with a bland rinse (1 teaspoon salt, 1 teaspoon baking soda in 4 cups of water) to maintain moisture, remove debris, and reduce plaque accumulation. 2 Avoid commercial mouthwashes with alcohol base or astringent properties. 2, 6
Adjunctive Antimicrobial Therapy
Add chlorhexidine gluconate 0.12-0.2% used twice daily for 60 seconds as FDA-approved adjunctive treatment for gingivitis. 6, 1 This should be used in addition to, not as a replacement for, mechanical plaque removal. 1
Alternative option: Green tea mouthwash (1-5%) demonstrates similar anti-plaque and anti-gingivitis effects to chlorhexidine if the patient cannot tolerate chlorhexidine. 6, 1
Special Populations
For denture wearers: Remove dentures, plates, and prostheses before brushing. 2, 6 Brush and rinse dentures after meals and at bedtime. 2, 6 Remove dentures from the mouth for at least 8 hours per 24-hour period and soak in rinsing solution. 2, 6
For patients with diabetes: Periodontal disease adversely affects glycemic control, and intensive periodontal treatment has been associated with A1C reduction from 8.3% to 7.8% after 12 months. 6, 5 These patients require particularly aggressive periodontal management.
For patients on hemodialysis: Expect higher rates of gingival bleeding due to platelet dysfunction and heparin use during dialysis. 2 These patients also have increased dental calculus formation due to elevated salivary pH, urea, and phosphorus levels. 2
Common Pitfalls to Avoid
Do not rely solely on antimicrobial mouthwashes without addressing mechanical plaque removal through professional cleaning and proper home brushing technique—this will fail to resolve the underlying gingivitis. 1
Do not use glycerin or lemon-glycerin swabs for oral moisturization, as these dry the mouth rather than moisturize it. 2
Do not discontinue anticoagulation for minor gingival bleeding, as the thrombotic risk typically outweighs the bleeding risk; instead, optimize local hemostatic measures. 2
Do not assume all gingival bleeding is benign gingivitis—persistent bleeding despite appropriate local measures mandates evaluation for systemic bleeding disorders, particularly in patients with no visible plaque or calculus. 3, 4