Bleeding or Painful Gums

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

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

Swollen GumsYesYesYesPossiblePossible
Painful GumsYesNoPossibleYesNo
Fever and MalaiseNoNoPossibleNoNo
Local IymphadenopathyPossibleNoYesNoNo

Possible Investigations



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.
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