Oral Hemorrhage and Periodontal Infections

• The most common source of spontaneous oral bleeding is gingivitis. Spontaneous oral hemorrhage may also be a result of systemic disease or medication. Examples include excessive iatrogenic anticoagulation (heparin, coumadin), leukemia, thrombocytopenia, blood dyscrasia, HIV, and liver disease.
• Other causes include recent extraction or other surgical procedure.

• With gingivitis, patients describe bleeding that occurs after brushing or flossing. Ask if there is a history of recent dental extraction or coagulopathy.
• Examination is straightforward. Identify the site of bleeding and look for evidence of underlying inflammation or recent dental procedure.
• If necessary, do a complete examination looking for other evidence of underlying disease i.e., petechiae, spider angiomata, etc.

• Simple gingival bleeding is usually controlled by direct pressure using folded gauze.
• Post-extraction bleeding can often be managed by evacuating residual clot and then having the patient bite down on folded gauze. If this fails, the EP can try local infiltration of lidocaine with epinephrine or placement of hemostatic material within the socket. Hemorrhage that is unresponsive to all measures mandates oral surgery or ENT consultation.
• Patients with underlying disease or coagulopathy also require directed therapy to correct the defect.

• Patients with minor bleeding secondary to gingivitis may be discharged home with referral to a general dentist and instructions on proper dental hygiene.
• Those patients with postextraction bleeding may also be discharged as long as bleeding has been controlled. Appropriate follow-up should be given. Instruct them to avoid activities such as smoking which can cause negative pressure within the mouth and dislodge existing clot.
• Those patients who have bleeding secondary to systemic disease or iatrogenic coagulopathy should be treated accordingly.

Gingivitis

• Gingivitis is an inflammatory response to plaque build-up at the gingival margins. It manifests as painless gum redness, swelling and bleeding.
• Treatment and prevention are via good oral hygiene including brushing and flossing as well as routine scaling in the dentist’s office. Antibiotics are not necessary. Untreated, gingivitis may progress to periodontitis.
• Other conditions can lead to gingival swelling and inflammation including pregnancy, leukemia, granulomatous diseases and multiple medications.

• Periodontitis is a result of gingivitis that has gone unchecked. This leads to separation of the gingiva from the tooth. The end result is further deposition of plaques and calculus in these periodontal pockets followed by destruction of the periodontal fibers that attach the tooth to the alveolar bone. Periodontitis is the main cause of tooth loss and decay.
• Patients may report halitosis and loose teeth. The condition is typically painless.
• Definitive treatment is done in the dentist’s office. Patients should seek timely follow-up.
• Periodontal abscess occurs when purulent debris becomes trapped within pockets created by separation of the gingiva from the tooth. It presents as localized swelling and, in contrast to periodontitis, is painful. Patients should be started on appropriate antibiotics (i.e., penicillin) and saline washes. Dental follow-up is encouraged. Occasionally, drainage is required.

• AKA trench mouth and Vincent’s angina, ANUG is caused by bacterial invasion of the gingival tissue. Risk Factors
• The primary risk factor is immunocompromise especially HIV.
• Other contributing factors include poor nutrition, stress, poor oral hygiene, and alcohol/ tobacco use.

• Anaerobes and spirochetes.

• Patients complain of painful, swollen gums and a foul metallic taste in their mouth. They may give a history of immunosuppression or other risk factor.
• Examination: The characteristic finding is ulcerated, swollen gingiva at the interdental areas (papillae). There is associated gingival bleeding and halitosis. Patients may also have pseudomembrane formation, lymphadenopathy and fever.

• Oral hygiene including hydrogen peroxide oral rinses.
• Antibiotics: appropriate agents include penicillin, clindamycin, and metronidazole.
• Analgesics

• The patient must follow-up with a general dentist for scaling, debridement and continued care.