DEPARTMENT OF PERIODONTICS

A SEMINAR ON

GINGIVAL BLEEDING

Presented by
SYED NABI AHMED
C.R.I.
INTRODUCTION
 The two earliest symptoms of gingival

inflammation proceeding established gingivitis are

(1) increased gingival crevicular fluid production rate

(2) bleeding from gingival sulcus on gentle probing.

 Gingival bleeding varies in severity, duration and
the ease with which it is provoked.
 Bleeding on probing is easily detectable clinically
& therefore is of value for the early diagnosis and
prevention of were advanced gingivitis.

Pregnancy gingivitis.
 It has been known that bleeding on probing

appears earlier than a change in color or other visual

signs of inflammation, in addition the use of

bleeding rather than color changes to diagnose early

gingival inflammation is advantages in that bleeding is a

were objective sign that requires less subjective

estimation.
CLASSIFICATION
Gingival bleeding can be due to a series of

factors, which can be grouped broadly into two

categories such as

 Local

 Systemic
 Local factors

a. Infectious

Acute : 1. ANUG (Acute Necrotizing

Ulcerative Gingivitis)

2. AHGS (Acute Herpetic

Gingive Stomatitis)

Chronic : 1. Gingivitis

2. Periodontitis
b. Traumatic

1. Brushing

2. Food impaction

3. Irritation (due to prosthesis)

4. Tooth pick injury

5. Gingival burns

c. Post Surgical

d. Congenital (eg) Hemangioma

 Systemic factors

a. Deficiencies

i) Hereditary : Haemophilia A & B, Von.wille

brand’s disease

ii) Liver disease: vit K deficiency

iii) Deficiency of factor II,VII,IX,X

iv) Idiopathic: eg.Thrombocytopenic purpura

v) Leubemic

vi) Nutritional :vit A, vit C and protein deficiency

b. Dysfunction
i) Multiple myeloma
ii) Systemic Lupus Erythematous

c. Drugs & chemical allergies

Salicylates, anticoagulant

d. Excess: Thrombocytosis

e. Defective aggregation

f. Infections: Infections mononucleuses

g. Hereditary: Haemorhagic telengetiasis

h. Hormones: Pregnancy, Menstruation

I. Malignancies
HISTOPATHOLOGICAL ALTERATION IN GINGIVAL
BLEEDING
In gingival inflammation the following
histopathological alterations result in abnormal bleeding:
 Dilatation & eugargeuant of capillaries is thinning
or ulceration of sulcular epithelium.

Gingival Inflammation
 Because the capillaries are engorged and closes to

the surface & the thinned, degenerated epithelium

is less protective, stimuli that are ordinarily

innocuous cause rupture of capillaries and gingival

bleeding.
GINGIVAL BLEEDING CAUSED BY LOCAL FACTORS
This can be divided into:
 Chronic & recurrent bleeding
 Acute
CHRONIC AND RECURRENT BLEEDING

 The most common cause of abnormal gingival

bleeding on probing is chronic inflammation.

 The bleeding is chronic or recurrent & is provoked

by mechanical trauma (e.g. from tooth brushing, tooth

picks or food impaction) or by biting into solid foods

such as apples.

Chronic Generalized diffused Gingivitis

ACUTE BLEEDING
 Acute episodes of gingival bleeding are caused by
injury or occur spontaneously in acute gingival
disease.
 Laceration of gingival by tooth brush bristles
during aggressive tooth brushing or by sharp pieces
of hard food can cause gingival bleeding even in the
absence of gingival disease.
 Gingival burrs from foods or chemicals increase
the ease of gingival bleeding.

Gingival enlargement seen

in a patient taking a
calcium channel blocker.
Gingival bleeding associated with systemic changes.
 In some systemic disorders, gingival
haemorrhage occurs spontaneously or after
irritation and is excessive and different to control.
Such conditions have the common feature of
hemostatic mechanism failure and result in abnormal
bleeding in the skin, internal organs and other
tissues including the oral mucosa.

 The various systemic conditions that can result

in gingival bleeding have been listed in the
classification.
CLINICAL EVALUATION OF GINGIVAL BLEEDING
Sites that bleed on probing have a greater area
of inflamed connective tissue (i.e., cell-ribs, collagens
per tissue) than do sites that do not bleed. In most
cases the cellular infiltrate of sites that bleed on
probing is predominantly lymphocytic. The severity of
bleeding and the ease with which it is provoked
depend on the intensity of inflammation. Hence they
can be grouped into two categories:
1. Spontaneous
2. Bleeding on provocation
• SPONTANEOUS BLEEDING or bleeding on slight
provocation can occur in acute necrotizing ulcerative
gingivitis. In this condition, engorged blood vessels in
the inflamed connective tissue are exposed by
ulceration of necrotic surface epithelium.

spontaneous bleeding of the gingiva

• BLEEDING ON PROVOCATION can be seen in varying
stages of the disease. In case of moderate or
advanced periodontitis, the presence of bleeding on
probing is considered a sign of active tissue
destruction.

bleeding of the gums

upon probing.
 Thus bleeding can be considered of diagnostic

value in many of the gingival diseases. However its

relationship to disease progression is unclean.

A periodontal probe or a wooden interdental

cleaves can be used in the evaluation of gingival

bleeding. It has to known that any force greater than

0.25N can produce gingival bleeding in healthy

tissues.
GINGIVAL BLEEDING INDICES
 The clinical assessment of gingival color, form and
texture is subjective in nature, gingival bleeding is
an objective diagnostic sign of inflammation.
 Periodontal probes are used with most indices
however toothpicks and dental floss are used to elicit
bleeding with some indices.
 Gingival bleeding indices are used in clinical
practice, surveys of population groups and clinical trials
of antiplaque and antigingivitis agents.
 Although there are many indices are available for
assessment of gingival bleeding.
Some which are used were commonly are as follows:

1. Gingival sulcus bleeding index

2. Gingival index-loe & sillness

3. Gingival bleeding index

4. Eastman interdental bleeding index

5. NIDCR protoacd for recording gingival bleeding

MANAGEMENT OF GINGIVAL BLEEDING

 Increased gingival bleeding and tenderness

requires routine periodontal monitoring.

 Periodontal maintenance should be titrated to

the individual patients need.

 Preventive care including a vigorous program of

oral hygiene is also vial.

 Hilder gingivitis eases respond well to scaling

and root planning with frequent oral hygiene

reinforcement.

 Some cases of gingivitis & bleeding may require

microbial culturing, antimicrobial mouthwashes and

local site delivery, or antibiotic therapy.

 Periodontal maintenance appointments may

used to be frequent when periodontal instability

is noted.
CONCLUSION
Gingival bleeding therefore is critical in early
diagnosis and prompt treatment of diseases involving
the periodontium. Proper awareness should be
inoculated in patients to consider bleeding as a early
sign of gingival disease. The woven diagnostic
techniques should also be used for their purpose.