Bleeding Gums: Causes and Management
Primary Cause and Initial Treatment
Bleeding gums are most commonly caused by gingivitis from inadequate plaque removal, requiring professional scaling and root planing followed by proper home oral hygiene as first-line treatment. 1
The American Dental Association identifies visible plaque and calculus accumulation as the primary etiology, with bleeding occurring during brushing when inflammation has developed but before progression to periodontitis (characterized by tooth mobility). 1
Systematic Assessment for Underlying Conditions
Evaluate for Systemic Contributors
The American College of Cardiology recommends assessing for anticoagulant use, thrombocytopenia, uremia, or liver disease in patients presenting with bleeding gums. 1
In patients with diabetes, periodontal inflammation is more severe and self-perceived gingival bleeding is more commonly reported compared to non-diabetic controls. 2
Patients with prediabetes demonstrate higher plaque index, bleeding on probing, and probing depths ≥4mm compared to controls, with underprivileged socioeconomic status further aggravating periodontal conditions. 2
Anticoagulation-Related Bleeding Risk
For patients taking warfarin, bleeding risk becomes clinically significant when INR exceeds 5.0, with exponential increases above 6.0. 3
Warfarin therapy increases bleeding risk in surgical procedures (odds ratio 2.9), while aspirin therapy is NOT an independent risk factor for bleeding complications. 4
For patients on aspirin (75-162 mg/day) for secondary prevention in diabetes with cardiovascular disease history, the ASCEND trial demonstrated increased major bleeding from 3.2% to 4.1%, with most excess being gastrointestinal and extracranial bleeding rather than oral bleeding. 5
Treatment Algorithm
Step 1: Professional Dental Intervention
- The American Dental Association recommends professional scaling and root planing with polishing as the essential first step, since calculus cannot be removed by regular brushing alone. 1
Step 2: Mechanical Plaque Control Education
- Instruct patients to use a small, soft-bristled toothbrush at least twice daily for a minimum of 2 minutes, ensuring the gingival portion of the tooth and periodontal sulcus are included in brushing. 1
Step 3: Adjunctive Chemical Plaque Control
Add 0.12-0.2% chlorhexidine gluconate used twice daily for 60 seconds as FDA-approved treatment for gingivitis. 1
Green tea mouthwash (1-5%) demonstrates similar anti-plaque and anti-gingivitis effects to chlorhexidine as an alternative. 1
Step 4: Regular Monitoring
- Schedule dental check-ups every 6 months to monitor for reduction in gingival bleeding, plaque accumulation, and improved gingival appearance. 1
Management in Patients on Anticoagulation
Warfarin Management
Do NOT discontinue warfarin for routine dental procedures including scaling and root planing when INR is therapeutic (typically 2.0-3.0). 3, 6
For INR 5.0-9.0 without active bleeding, withhold 1-2 doses of warfarin and monitor serial INR determinations; add oral vitamin K 1.0-2.5 mg only if the patient has increased bleeding risk factors (advanced age >65 years, history of bleeding, concomitant antiplatelet drugs). 3
For INR >10 without bleeding, immediately withhold warfarin and administer oral vitamin K 5 mg. 3
For active bleeding with elevated INR, administer 5-10 mg IV vitamin K by slow infusion over 30 minutes; if life-threatening, add 4-factor prothrombin complex concentrate (PCC) 25-50 U/kg IV. 3, 6
Aspirin Management
Continue aspirin therapy for patients on secondary prevention (history of cardiovascular events) during routine dental procedures, as discontinuation poses greater thrombotic risk than bleeding risk. 5, 4
Aspirin therapy was not an independent risk factor for bleeding in skin cancer surgery (odds ratio not significant), unlike warfarin. 4
For patients on aspirin for primary prevention in diabetes, the modest cardiovascular benefit (12% reduction in vascular events) is balanced by comparable bleeding risk increase (3.2% to 4.1%), but oral bleeding is not the predominant concern. 5
Special Considerations in Diabetes
Diabetes and periodontitis contribute to each others' severity through shared inflammatory pathways, with periodontal treatment that reduces gingival inflammation aiding in hyperglycemia control. 7
Patients with diabetes are at increased risk of developing periodontitis, and diabetics with untreated periodontitis have more difficulty controlling serum glucose. 7
Target periodontal treatment aggressively in diabetic patients, as gingival crevicular fluid contains inflammatory mediators that worsen glycemic control. 7
Critical Pitfalls to Avoid
Never delay dental treatment to normalize INR in patients with therapeutic anticoagulation (INR 2.0-3.0), as available evidence shows no correlation between INR at presentation and outcomes of dental bleeding. 6
Do not routinely discontinue aspirin before dental procedures, as the thrombotic risk outweighs bleeding risk. 4
Avoid excessive vitamin K administration (>10 mg) in warfarin patients, as this creates warfarin resistance for up to a week and makes re-anticoagulation difficult. 3
Recognize that bleeding occurring at INR <3.0 is frequently associated with underlying lesions in the gastrointestinal or urinary tract rather than anticoagulation alone. 6
In patients with mechanical prosthetic heart valves and elevated INR, avoid rapid INR correction with IV vitamin K due to valve thrombosis risk; allow gradual decline instead. 3