Management of bleeding gums
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management of bleeding gums gingivitis treatment guidelines 2024
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I now have comprehensive information from both textbooks and web sources. Here is the full management guide:
Management of Bleeding Gums
Bleeding gums (gingival bleeding) is one of the most common oral complaints. The first step is always identifying the underlying cause, because treatment is cause-directed.
Causes at a Glance
Table: Causes of Gingival Bleeding (Scott-Brown's Otorhinolaryngology, Head & Neck Surgery)
| Local Causes | Systemic Causes |
|---|---|
| Chronic gingivitis | Pregnancy (exacerbates gingivitis) |
| Chronic periodontitis | Leukaemia |
| Acute necrotizing gingivitis (ANG) | HIV infection |
| Angioma / telangiectasia | Clotting defects |
| Anticoagulant drugs | |
| Scurvy (vitamin C deficiency) | |
| Other causes of purpura |
1. Simple / Chronic Gingivitis
This is the most common cause and is fully reversible with proper management.
Goals: Reduce inflammation by eliminating the causative plaque biofilm.
Step 1 - Oral Hygiene (First-line)
- Brush teeth twice daily with a soft-bristled toothbrush using correct technique
- Floss once daily to remove interproximal plaque
- These measures alone can resolve early gingivitis completely
Step 2 - Antiseptic Mouth Rinses (moderate/severe)
- Chlorhexidine 0.12-0.2% - preferred agent, antibacterial rinse
- 3% hydrogen peroxide diluted 1:1 with warm water - alternative
- Warm saline rinses for symptomatic relief
Step 3 - Professional Dental Care
- Scaling and root planing (SRP) - professional removal of plaque and calculus (tartar), including subgingival deposits
- Referred to dentist/periodontist for regular cleanings every 6 months (or more frequently for established disease)
(ROSEN's Emergency Medicine, Scott-Brown's)
2. Necrotizing Periodontal Disease (Acute Necrotizing Gingivitis / ANUG)
A more severe, painful form often seen in immunocompromised patients (HIV, poorly controlled diabetes, immunosuppressive therapy).
Management:
- Requires dentist-led debridement of necrotic tissue - cannot be managed with hygiene alone
- Oral antimicrobials are indicated for:
- Extensive disease
- Immunocompromised patients
- Systemic symptoms (fever, lymphadenopathy)
Recommended antibiotics (ROSEN's Emergency Medicine, Table 56.2):
| Antibiotic | Dose | Duration | Notes |
|---|---|---|---|
| Penicillin V | 500 mg TID-QID | 10 days | First-line |
| Amoxicillin/clavulanate | 500 mg/125 mg TID | 10 days | Alternative |
| Metronidazole | 500 mg BID | 10 days | If penicillin allergy |
| Clindamycin | 300 mg QID | 10 days | If penicillin allergy |
| Nystatin (swish/spit) | 100,000 units/mL, 5 mL QID | 10 days | If immunocompromised or candidal infection suspected |
Pain management:
- Ibuprofen 400-600 mg every 6-8 hours (NSAID, first-line - also reduces gingival inflammation)
- Paracetamol 650 mg every 6 hours
- Severe pain: opioid analgesics
- Topical viscous lidocaine - apply only to small areas (risk of systemic toxicity if swallowed in large amounts)
Smoking cessation - the most common modifiable risk factor in HIV-negative patients; all patients who smoke must be counselled.
3. Systemic Causes - Key Management Points
| Cause | Specific Management |
|---|---|
| Pregnancy gingivitis | Reinforce oral hygiene; professional cleaning safe in 2nd trimester; resolves postpartum |
| Anticoagulant drugs | Review medication with prescribing physician; local hemostatic measures; do not stop anticoagulants without medical advice |
| Leukaemia / blood dyscrasias | Haematology referral; treat underlying disorder; local measures |
| Scurvy | Vitamin C supplementation (500-1000 mg/day); dietary correction |
| HIV-associated disease | Antiretroviral therapy optimization; aggressive periodontal management |
| Diabetes | Glycaemic control improves periodontal outcomes (bidirectional relationship) |
| Clotting defects | Haematology input; local hemostatic agents (oxidized cellulose, tranexamic acid mouthwash) |
4. Follow-up and Referral
- Simple gingivitis: Non-urgent dental referral (1-2 weeks)
- Acute necrotizing gingivitis: Dentist review within 24-72 hours for repeat debridement
- Severe necrotizing disease: Emergency dental consultation within 24 hours
- Systemic symptoms (fever, lymphadenopathy) or immunocompromised with severe disease: IV antibiotics + emergency dental consultation
5. Prevention
- Brush twice daily, floss daily
- Regular professional dental cleanings (6-monthly)
- Stop smoking / tobacco use
- Control systemic conditions (diabetes, nutritional deficiencies)
- Limit excess sugar and alcohol
- Avoid medications known to cause gingival hyperplasia where possible (e.g., phenytoin, cyclosporin, calcium channel blockers)
Sources:
- ROSEN's Emergency Medicine: Concepts and Clinical Practice - Gingivitis and Periodontitis chapter
- Scott-Brown's Otorhinolaryngology Head & Neck Surgery - Periodontal Disease chapter (Table 42.2)
- StatPearls - Gingivitis (NCBI)
- Medscape - Gingivitis Treatment
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