How to Manage Spontaneous Gingival Hemorrhage

Spontaneous gingival hemorrhage

A patient presents with copious gingival bleeding:

• • Bleeding is prolonged and cannot be stopped with pressure
  • Several such episodes have occurred recently without provocation

Presentation

Population

• Variable demographics depending upon the nature of the underlying disorder
• Possible family history of a bleeding disorder

Signs

• Hemorrhage emanating from gingival sulci with minimal or no provocation (Fig. 1)
• May present with any of the following:
  • Submucosal and/or subcutaneous hemorrage (petechiae, ecchymoses, or hematoma)
  •  Hyperplasic gingival tissues, oral ulceration and oral infection (e.g., herpes simplex virus, candidiasis)
  • Swollen joints (hemarthrosis)
  • Signs of an underlying systemic disease (e.g., jaundice, spider angiomas, ascites, pallor, lymphadenopathy)

Symptoms

• Prolonged bleeding after injury, trauma or dental/surgical procedures
• Bleeding episodes
  • Menorrhagia or postpartum hemorrhage
  • Epistaxis
  • Gastrointestinal (e.g., hematemesis, melana)
• Fatigue
• Recurrent infections and fever

Investigation

1. Obtain a detailed medical and dental history:
   1. Personal and familial history of bleeding problems
   2. Dental history: severe or prolonged bleeding following trauma, extractions or surgical procedures
   3. Medications and illnesses that may be associated with excess bleeding
2. Inspect the visible skin and perform an intraoral examination.
3. Assess for other potential causes of oral hemorrhage:
   • Mucocutaneous disorders (e.g., desquamative gingivitis [erosive lichen planus, pemphigus vulgaris, mucous membrane pemphigoid and erythema migrans])
   • Necrotizing ulcerative gingivitis
   • Drug-induced gingival hyperplasia
   • Gingivitis of a local or endocrine (puberty, pregnancy) cause
   • Periodontitis

Hemorrhage that is evoked with minimal provocation or spontaneously, especially if prolonged and difficult to control, should alert the clinician to an underlying bleeding disorder.

Diagnosis

• A hematologist will perform a focused history, physical examination, and laboratory studies that may include specific coagulation factor assays, mixing studies and platelet aggregation tests.
• If leukemia is suspected, diagnosis is confirmed by peripheral blood smear and bone marrow biopsy for cytology, immunophenotyping, and molecular/cytogenetic studies.

Differential diagnosis

• Local pathologies (see the Investigation section)
• Systemic disorders:

• Nonthrombocytopenic purpura
  • Vascular disorders (e.g., scurvy, Ehlers-Danlos syndrome, hereditary hemorrhagic telangiectasia)
  • Disorders of platelet function (e.g., inherited disorders [Bernard-Soulier syndrome, von Willebrand disease], medications [ASA, NSAIDs], alcoholism, uremia)

• Thrombocytopenic purpura
  • Decreased platelet production (e.g., myelofibrosis, leukemia, myelodysplastic syndromes, chemotherapy, radiotherapy, skeletal metastasis)
  • Increased platelet destruction (e.g., immune thrombocytopenic purpura)
  • Platelet sequestration (e.g., splenomegaly)

• Disorders of coagulation
  • Inherited (e.g., hemophilia A and B)
  • Acquired(e.g., liver disease, vitamin K deficiency, medication [warfarin, heparin])

Treatment

Common Initial Treatment

1. Bleeding can usually be controlled by local measures:
   • Pressure with moistened gauze
   • Absorbable gelatin, absorbable collagen, microfibrillar collagen or oxidized regenerated cellulose (to provide a scaffold for platelets to adhere)
   • Thrombin (to convert fibrinogen to fibrin)
   • Epsilon-aminocaproic acid or tranexamic acid oral rinses (to reduce fibrinolytic activity)
   • Soft diet and avoiding factors that may provoke bleeding, such as strenuous activities, traumatic brushing, flossing, and rinsing
   • If pre-existing dental models are available, a vacuum-formed splint (+/- lined with thrombin powder) can be fabricated and used to apply additional pressure and protection
2. Screening serologic studies should be performed.
   • Complete blood count (CBC) with platelet count
   • International normalized ratio (INR): measures the factors of the extrinsic and common coagulation pathways
   • Partial thromboplastin time (PTT): measures the factors of the intrinsic and common coagulation pathways
   • Thrombin time (TT): tests the ability of fibrinogen to form an initial clot
   • Platelet function analyzer (PFA-100) or ivy bleeding time (BT): screens for functional platelet disorders
3. If the bleeding cannot be controlled, assessment with a physician and systemic measures are necessary.
4. Definitive medical management depends on the nature of the underlying disorder. Principal agents for systemic management include platelet infusion, fresh frozen plasma, factor concentrates, cryoprecipitate, desmopressin (DDAVP) and antifibrinolytic therapy.

Advice

• Consider the possibility that bleeding disorders may first manifest in a dental setting. Refer the patient to an oral pathologist or physician if is there is any clinical suspicion.
• Most dental care can be provided with minimal modification for patients with a known bleeding disorder; consult with their physician or hematologist if in doubt.
• Based on the nature and severity of a bleeding disorder and the type of dental procedure, care may be most appropriate in a hospital setting.

THE AUTHORS

	Dr. Klieb is a staff oral pathologist at Sunnybrook Health Sciences Centre, a University of Toronto-affiliated hospital, with cross appointments in the departments of dentistry and anatomic pathology.
	Dr. Gilbert is an MSc candidate at the University of Toronto and a staff dentist at Sunnybrook Health Sciences Centre with interest in dental management of the medically compromised patient.

Correspondence to: Dr. Hagen Klieb, Sunnybrook Health Sciences Centre, Suite H126, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5. Email: hagen.klieb@sunnybrook.ca