Mouth conditions, bleeding and painful gums

Probability diagnosis

Factitious: excessive brushing

Gingivitis/periodontal (gum) disease

Trauma: poor-fitting or partial dentures

Drugs: warfarin overdose, phenytoin

Serious disorders not to be missed

Oral cancer/benign neoplasms (e.g. epulis, SCC)

Blood dyscrasias (e.g. AML)

General coagulation defects

HIV/AIDS

Acute herpetic gingivostomatitis

Pitfalls (often missed) but uncommon

Acute necrotising ulcerative gingivitis (Vincent infection)

Autoimmune disease (e.g. lichen planus, SLE)

Hereditary haemorrhagic telangiectasia

Malabsorption

Nutritional deficiency (e.g. scurvy)

Hormonal (e.g. pregnancy)

Key clinical features

Erythematous bleeding gums are a common worldwide problem, which is almost always a localised inflammation associated with poor dental hygiene. Systemic problems usually as part of a bleeding diathesis need to be considered.

   Acute necrotising ulcerative gingivitis (Vincent infection or trench mouth), which is caused by anaerobic organisms, is rarely seen but is more common in undernourished or ill young adults under stress. Haematological disorders such as coagulation defects, acute leukaemia and agranulocytosis need to be excluded. Investigation may not be necessary but consider:

• FBE

• ESR

• wound swab

• autoimmune screen

• INR.

Consider dental referral.