Bleeding or Painful Gums

The primary cause of this symptom is nearly always infection, usually because of poor dental hygiene: An endemic problem worldwide. Systemic problems may also cause gum pain or bleeding. While a dental referral is likely to be the end result, it is worth checking for general causes or easily remediable problems before directing the patient to the dentist.

Published: 2nd August 2022 | Updated: 15th August 2022

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

Swollen GumsYesYesYesPossiblePossible
Painful GumsYesNoPossibleYesNo
Fever and MalaiseNoNoPossibleNoNo
Local IymphadenopathyPossibleNoYesNoNo

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.
Report errors, or incorrect content by clicking here.
Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.