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Probability diagnosis

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Factitious: excessive brushing

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Gingivitis/periodontal (gum) disease

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Trauma: poor-fitting or partial dentures

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Drugs: warfarin overdose, phenytoin

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Serious disorders not to be missed

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Oral cancer/benign neoplasms (e.g. epulis, SCC)

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Blood dyscrasias (e.g. AML)

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General coagulation defects

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HIV/AIDS

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Acute herpetic gingivostomatitis

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Pitfalls (often missed) but uncommon

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Acute necrotising ulcerative gingivitis (Vincent infection)

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Autoimmune disease (e.g. lichen planus, SLE)

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Hereditary haemorrhagic telangiectasia

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Malabsorption

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Nutritional deficiency (e.g. scurvy)

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Hormonal (e.g. pregnancy)

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Key clinical features

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Erythematous bleeding gums are a common worldwide problem, which is almost always a localised inflammation associated with poor dental hygiene. Systemic problems usually as part of a bleeding diathesis need to be considered.

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   Acute necrotising ulcerative gingivitis (Vincent infection or trench mouth), which is caused by anaerobic organisms, is rarely seen but is more common in undernourished or ill young adults under stress. Haematological disorders such as coagulation defects, acute leukaemia and agranulocytosis need to be excluded. Investigation may not be necessary but consider:

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  • FBE

  • ESR

  • wound swab

  • autoimmune screen

  • INR.

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Consider dental referral.

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