Bleeding or Painful Gums
Differential Diagnosis
Common Diagnoses
- Gingivitis/Periodontal (Gum) Disease
- Pregnancy Gingivitis
- Acute Necrotising Ulcerative Gingivitis (ANUG): Vincent’s Stomatitis
- Trauma: Poorly Fitting Dentures
- Drugs: Warfarin Overdosage, Long-Term Phenytoin
Occasional Diagnoses
- Aphthous Ulceration
- Acute Herpetic Gingivostomatitis (Occasionally EBV)
- Autoimmune Disease: Lichen Planus, SLE and Others
- Oral Neoplasia (Commonest is SCC) (Note: May Bleed but Usually Painless)
- Blood Dyscrasias (Especially Acute Myeloid Leukaemia)
Rare Diagnoses
- Malabsorption (Including Scurvy)
- Chemical Poisoning: Mercury, Phosphorus, Arsenic and Lead
- Hereditary Haemorrhagic Telangiectasia
- Lymphangioma
- Cavernous Haemangioma
Ready Reckoner
Key distinguishing features of the most common diagnoses
| Gingivitis | Pregnancy | ANUG | Trauma | Drugs | |
|---|---|---|---|---|---|
| Swollen Gums | Yes | Yes | Yes | Possible | Possible |
| Halitosis | Yes | No | Yes | No | No |
| Painful Gums | Yes | No | Possible | Yes | No |
| Fever and Malaise | No | No | Possible | No | No |
| Local Iymphadenopathy | Possible | No | Yes | No | No |
Possible Investigations
Likely:None.
Possible:FBC.
Small Print:Swab, INR, autoimmune screen, Paul–Bunnell test.
- FBC: To check for blood dyscrasias and malabsorption.
- Swab may help if obscure infective cause.
- Urgent INR if patient on warfarin.
- Paul–Bunnell test: EBV infection may cause gingivostomatitis.
- Autoimmune screen if autoimmune disease suspected.
Top Tips
- Patients with manifestly ‘dental’ problems may attend the GP because they view the doctor’s service as cheaper or more accessible. Direct them firmly to the dentist to discourage inappropriate attendance in the future.
- Review the patient’s medication – it is easy to overlook iatrogenic causes of gum soreness or bleeding.
- Patients with aphthous ulcers are likely to have read that their problem is associated with vitamin deficiencies or systemic illness. In primary care, it almost never is.
- Ulcerative gingivitis can often be diagnosed as soon as the patient walks into the consulting room, because of the characteristic odour.
Red Flags
- Children with primary attacks of herpetic gingivostomatitis can become quite ill and dehydrated. Consider early review or admission.
- Petechiae on the soft palate in conjunction with gingivostomatitis raise the possibility of EBV infection, acute leukaemia or scurvy.
- Enquire about skin problems elsewhere, or you may miss a significant diagnosis – SLE, pemphigus, pemphigoid, bullous erythema multiforme, epidermolysis bullosa and lichen planus can all affect the mouth.