We don’t typically think of bleeding gums in response to gently poking or prodding as a medical concern. It’s far more common for us to think of bleeding gums as a dental concern, one that’s due to brushing too hard, poor oral hygiene, gingivitis, recent onset of flossing, or poorly fitting dentures. Because most providers tend to think of bleeding gums within this context, patients are typically advised to follow up with their dentists regarding such concerns. In this article, I'll share three commonly overlooked medical contributing factors to the symptom of bleeding gums that should be considered before referring patients to their dentists.
1. Your patients’ bleeding gums may be a side effect of their medication.
With estimates suggesting that as much as 68.1% of American adults may be taking at least one prescription medication daily, it’s important to consider the possibility that bleeding gums may actually be a medication side effect [1]. The list of drug classes that could contribute to bleeding gums is more expansive than many people think. Of course, the first drug class that comes to mind is anticoagulants or blood thinners, like warfarin or heparin, since they reduce the blood’s ability to clot.
Furthermore, aspirin can contribute to bleeding gums, and cardiovascular medications, including anti-arrhythmic medications, calcium channel blockers, angiotensin-converting enzyme inhibitors, beta blockers, and diuretics can each contribute to gingival overgrowth. Gingival overgrowth involves a build-up of gum tissue where the tissue can become so swollen that it begins to grow over the teeth, making them difficult to brush and keep clean. As a result, gingival overgrowth frequently creates a breeding ground for bacterial infection, which can contribute to swollen, irritated, and bleeding gums.
Many antidepressants have a side effect of xerostomia or dry mouth, and the decrease in saliva can lead to tooth decay, gum disease, and other oral problems. Because saliva exerts direct antimicrobial activity [2], xerostomia increases the likelihood of bacterial infections in the mouth. Bacterial infections in the oral cavity increase the likelihood of gingival swelling and bleeding gums.
2. Your patients’ bleeding gums may be due to a vitamin deficiency.
Because it plays a critical role in blood clotting, low levels of vitamin K can contribute to gingival bleeding. Unless an increase in vitamin K levels is contraindicated, patients can typically increase their vitamin K levels by increasing their dietary intake of green leafy vegetables, such as spinach, kale, mustard greens, parsley, turnip greens, collards, Swiss chard, romaine, and green leaf lettuce.
Research also demonstrates that bleeding gums in response to gentle probing may actually be a sign of a nutritional deficiency. In a recent study, researchers found that bleeding gums were associated with low levels of vitamin C in the bloodstream. [3] Researchers further urged that setting the stated requirements for ascorbic acid based on the goal of scurvy prevention was leading to a daily amount that was too low to prevent ascorbic acid-deficiency-induced gingival bleeding. They further suggested that low ascorbic acid plasma levels may reflect systemic microvascular pathology, and that the pathology is reversible with increased intake of vitamin C.
Patients can increase their blood levels of vitamin C by increasing their intake of vitamin C-containing foods, such as citrus fruit, peppers, strawberries, and blackcurrants; utilizing oral supplementation with vitamin C; or through intravenous nutrient therapy.
3. Your patients’ bleeding gums may be due to hyperglycemia.
Hyperglycemic states lead to increased amounts of sugar in the saliva. This retards some of the saliva’s antimicrobial activity, leading to a buildup of plaque and bacteria. The plaque and microbes irritate the gums, leading to oral concerns such as gingival bleeding, gingivitis, halitosis, dental caries, and tooth loss. If your patients report bleeding gums, it will be of value to ensure that their blood sugar levels are well-controlled and ideally within the optimal range.
Summary
To summarize, there are multiple medical contributing factors to gingival bleeding, and these factors should be considered and/or explored prior to referring our patients back to their dentists when they report bleeding gums. These factors include medication side effects, specifically side effects of anticoagulants, antihypertensives, and antidepressants; nutrient deficiencies, specifically deficiencies of vitamins C and K; and uncontrolled or unaddressed hyperglycemia. By looking into and addressing these concerns when indicated, we can practicing whole-person, responsible care and ensure that our patients receive the high-quality care they deserve and have come to expect from our services.
[1] Zhong, W., Maradit-Kremers, H., St Sauver, J. L., Yawn, B. P., Ebbert, J. O., Roger, V. L., Jacobson, D. J., McGree, M. E., Brue, S. M., & Rocca, W. A. (2013). Age and sex patterns of drug prescribing in a defined American population. Mayo Clinic proceedings, 88(7), 697–707. https://doi.org/10.1016/j.mayocp.2013.04.021
[2] Vila, T., Rizk, A. M., Sultan, A. S., & Jabra-Rizk, M. A. (2019). The power of saliva: Antimicrobial and beyond. PLoS pathogens, 15(11), e1008058. https://doi.org/10.1371/journal.ppat.1008058
[3] Hujoel, P. P., Kato, T., Hujoel, I. A., & Hujoel, M. (2021). Bleeding tendency and ascorbic acid requirements: systematic review and meta-analysis of clinical trials. Nutrition reviews, nuaa115. Advance online publication. https://doi.org/10.1093/nutrit/nuaa115