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From Trisha's Desk Trisha E. O’Hehir, RDH, BS, Hygienetown Editorial Director

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Is Gingival Bleeding Serious?
– by Trisha E. O’Hehir, RDH, BS, Hygienetown Editorial Director

Bleeding on probing is a standard part of a periodontal examination. We count the numbers of bleeding points and report to patients the seriousness of their infection. Before we can even finish a sentence, the patient interjects with “It’s no big deal. My gums always bleed and my parents had bleeding gums too. It’s just normal for me.”
Is bleeding normal? Is bleeding a big deal or not? The first signs of gingivitis are swelling and redness, not bleeding. That comes a few days later. The bacteria in the biofilm dump toxic waste into the fluid channels around the biofilm towers and mushrooms and it makes its way out of the biofilm into the surrounding area (the sulcus of the biofilm is located subgingivally). From the sulcus, these toxins pass through the usually strong barrier of the junctional epithelium, made more permeable by volatile sulfur compounds (VSCs) associated with bad breath. After they pass the junctional epithelium, these toxins trigger the immune response, sending white blood cells to the area to phagocytize the bacteria that are dumping the toxic waste.

To get to the sulcus, the white blood cells must leave the blood vessels in the connective tissue and travel cell to cell through the connective tissue and the epithelium to eventually get to the sulcus. This process brings fluid into the connective tissue around the blood vessels, causing swelling of the tissue. It also breaks down the glue holding the cells together, making it harder for oxygen molecules to reach cells. Oxygen is needed for adenosine triphosphate (ATP) production essential for life of the cells. To repair the problem, the circulatory system begins building capillary loops closer to the surface, to better deliver oxygen molecules to the outer epithelial cells. This accounts for the redness of the tissue.

With limited oxygen and consequently limited ATP production, the cells lining the sulcus multiply but are not capable of maturing due to the lack the ATPs. The VSC production from many sources in the subgingival areas also interferes with junctional epithelial cell function. Granulation tissue forms and now the periodontal probe passes easily through the junctional epithelium (JE) into the capillary loops, causing the bleeding you see. Bleeding signals progression from superficial swelling and redness to more underlying tissue destruction.

Bleeding is a big deal when you consider the cell level changes that must take place for the probe to penetrate the JE and hit a blood vessel. Bleeding allows bacteria and their toxins to easily pass into the circulatory system and move to other parts of the body. It’s a big deal.

Bleeding can be checked in two ways, either the periodontal probe or using a triangular shaped toothpick. The toothpick test or Eastman Interdental Bleeding Index (EIBI) is so easy patients can do it themselves. That way they can’t blame you for poking them so hard they bled. Simply rub a triangular wooden toothpick between the teeth four times, from the facial surfaces only. Then look for bleeding on both facial and lingual interproximals. It’s a very reliable measure of interdental inflammation, confirmed by microscopic evaluation of surgically removed papilla. Teach patients to do this perio self-test daily and you’ll no longer need to give flossing lectures.

Patients who think bleeding gums are normal don’t have all the facts. Just ask them where they think the blood comes from? It should start a very interesting conversation.

Inside This Section
94 Perio Reports
98 Message Board: Is This Perio or Not?
100 Profile in Oral Health: Bacterial Biofilm and Inflammation
103 Hygienetown.com Poll: Ankyloglossia
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