Introduction - Alexandria Drysten Professional Portfolio
Literature Review:The Causes of Gum Bleeding and HowIt Can Be PreventedAlexandria DrystenUniversity of BridgeportTable of Contents TOC \o "1-2" \h \z \u Introduction PAGEREF _Toc5518443 \h 3Problem PAGEREF _Toc5518444 \h 6Purpose PAGEREF _Toc5518445 \h 7Significance of the Study PAGEREF _Toc5518446 \h 7Definition of Terms PAGEREF _Toc5518447 \h 7Limitations of Study PAGEREF _Toc5518448 \h 8Research Methodology PAGEREF _Toc5518449 \h 8Poor oral hygiene and gum bleeding PAGEREF _Toc5518450 \h 10Medications and gum bleeding PAGEREF _Toc5518451 \h 11Illness and gum bleeding PAGEREF _Toc5518452 \h 12Vitamin Deficiency and Gum bleeding PAGEREF _Toc5518453 \h 12Water flossing vs traditional flossing and gum bleeding PAGEREF _Toc5518454 \h 14Mouth breathing and gum bleeding PAGEREF _Toc5518455 \h 17Crowding teeth and gum bleeding PAGEREF _Toc5518456 \h 18Pregnancy and gum bleeding PAGEREF _Toc5518457 \h 18Periodontal therapy (scaling and root planning) and gum bleeding PAGEREF _Toc5518458 \h 20Discussion / Conclusion PAGEREF _Toc5518459 \h 20Appendix 1. PAGEREF _Toc5518460 \h 23References PAGEREF _Toc5518461 \h 24IntroductionGum bleeding is a major occurrence in a quest for oral health. Bleeding gums is a physical warning sign to poor dental health and an indication to act now. As a registered dental hygienist, practicing for almost three years, I witness bleeding gums several times a day, which leads me to my topic, bleeding gums. In hygiene school, students are taught that, “healthy gums don’t bleed.” It has been my experience that most of my new patients have gum bleeding at home. It is well known that regular periodontal health maintenance and oral health education has a positive effect on oral health. One example of this is in a study of one hundred and fifty medical college students who were studied over a three-year period. These students were randomly divided into two groups. Group A received oral health education which included the right way to brush teeth, the use of dental floss and the use of the interdental brush. Group B had no intervention. Several before and after indices were taken such as bleeding on probing (BOP) and gingival index (GI). Statistical analysis resulted in statistical significantly differences between Group A and Group B as expected. It was concluded that “There are positive effects of regular periodontal health maintenance and oral health education on periodontal health.” (Ge, Lin, Guo, Ni, Qian, and Shu,?2017)For my research, I am digging further in depth as to the causes of gum bleeding and how it can be prevented. In order to support my literature research, I have performed a quazi research investigation of my own along with reviewing previous recorded research. The purpose of this survey was to see if bleeding gums is the norm as well as to get an overview of the oral health of the patients in my practice. With permission from the dentist I work with, I created a six-question survey to ask my patients before I clean their teeth. (See Figure 1) This is an exploratory informational survey, I used the anonymous data to draw conclusions based on the patient’s responses. The participants were 25 consecutive patients who came in for their re-care visit (23) or were new to my office (2) for one specific week. Figure 1: Patient SurveyThe last few lines of the survey contain comment lines where I added details, without revealing the identity of the patient. For example, I added the patient’s general periodontal status (probe depths, recession and mobility), I recorded if the patient is taking any medication that can have gum bleeding as a side effect and if the patient is a mouth breather or not. (This data is not presented in this paper) The Raw data of the six questions is presented in Appendix 1. The results showed that overall 11 of the 25 surveyed had bleeding gums (44 percent) at home, with males having more gum bleeding 62.5 percent compared to female’s 35.3 percent. See Table 1 below.Table 1: Descriptive statistics for the dental hygiene surveySexNGums BleedGums Don't BleedMales853Females17611total251114The mean number of months since the last cleaning was 5.96 with a range of 3 to 18 months. It should be noted that there were two outliers of 12 and 18 months since last cleaning, both were new patients to our office. Ten patients used manual toothbrushes while 15 used an electric toothbrush. Only one of the 15 patients who used the electric toothbrush reported gum bleeding whereas four of the eight patients (I did not include the two new patients) who used a manual toothbrush had gum bleeding. Most patients used a combination of toothbrushing and flossing or other device with only four patients who used the toothbrush method alone, three of the four admitted to gum bleeding at home. Most patients brushed two times a day with four admitting to once or twice a day and two saying they brushed two to three times a day. What assumptions can I make? As the dental hygienist for 23 of the patients, I am doing a pretty good job educating my patients with the importance of oral hygiene. I will have to work on the two new patients. In an exploratory study such as this there is always the possibility of error. Such an error could have been that patients were not telling the “truth” when asked if their gums bleed. From experience, I know first-hand that when I ask some patients if their gums bleed, and they reply no, that their gums tell a different story when I begin to work on them. Overall, I feel that I really stress oral hygiene instructions and home care with my patients and this can in turn have a positive effect on how well they report the care of their teeth. ProblemBleeding is the first sign and indication of periodontal disease. Weather the patient is having signs of gingivitis (reversible) or periodontitis (non-reversible), bleeding is a sign to act now to improve oral health. Periodontal disease does not just appear overnight. It goes through a process of stages… first starting with gingivitis. Gingivitis is usually caused by bacteria and plaque that is not effectivity removed by brushing and flossing. Left untreated, this can turn into periodontitis, which can lead to bone loss, pocketing, subgingival calculus (tarter below the gum line), and will most likely need non-surgical treatment in order to maintain the condition. According to the American Dental Association (ADA) “Ninety-one percent of Americans over 20 have had cavities at some point in their lives.” This is a problem. (ADA News Releases, 2015). With all of the advances we have to prevent dental disease, we do not take advantage of the knowledge or opportunity. Dental infections can add up, with both your health and your wallet at stake. According to the?Centers for Medicare and Medicaid, Americans spent an estimated $117 billion on dental services in 2015. (Frank, 2017) Gum bleeding is the first sign of gingivitis and periodontitis. If bleeding gums are treated in early stages, the advancement of periodontal disease can be avoided. PurposeThe purpose of this study is to identify the reasons for gum bleeding and the different methods of reducing or eliminating it. This will aid me in my everyday work practice. I will be able to with confidence, evaluate the cause of each patients gum bleeding. I will further be able to recommend the appropriate method to correct it and prevent it from happening. Or if it has progressed to periodontal disease, recommend the procedures necessary to correct or arrest the disease.Significance of the Study People have teeth, and most people experience gum bleeding at one time or another. The significance of this study is to identify the many causes of gum bleeding. In turn, once aware of what causes gum bleeding, focus on how to eliminate and prevent bleeding gums. This study will go in depth into the causes of gum bleeding and the different methods used to clean and maintain the oral cavity in between recare visits to the hygienist. Periodontal disease is one of the most common diseases and can be prevented. One of the most common responses I hear when I inform a patient that they have bleeding gums and active infection in their mouth is, “My gums have always bleed”. This is where that statement needs to end. If your body started bleeding when, you shower and “clean” your body, one would be concerned. Again, “healthy gums don’t bleed”. Definition of TermsGingivitis: inflammation of the gumsPeriodontitis: inflammation of the gums involving supporting structuresPeriodontal disease: a dental infection caused by bacteria in the plaque. Gingivitis is the earliest stage of periodontal disease whereas, periodontitis is the more advanced stageProbing: measuring pocket depths around the tooth to determine the health or disease of the periodontiumPeriodontium: specialized tissues that both surround and support the teeth maintaining them in placeRecession: receding gums causing exposure of the roots. This is caused from a loss of gum tissue around the “crown” of the toothCrown of tooth: The visual portion of the tooth in one’s mouth that is covered by enamel Enamel: The hardest and most mineralized area in the human body. It covers the outer layer of each tooth that is visible in the human mouthXerostomia: Dry mouthSubgingival calculus- tarter below the gum lineLimitations of StudyLimitations of the study are always inevitable. One limitation I would say would be getting “honest” information from patients. I always wonder why people feel the need to be dishonest to their dental professionals when it is evident through our examination weather or not this individual is doing what they say. Another limitation is that although improper home care is the most common reason for gum bleeding, other factors can play a role. For example, crowding teeth, genetics, mouth breathing, side effects from medications, pregnancy and more can all play a role that can lead to gum bleeding. At times, it could be difficult to determine the underlying cause of gum bleeding for each specific patient. Research MethodologyIn order to investigate what is known, I did a literature review using the PubMed/MEDLINE database, which is maintained by the United States National Library of Medicine. The searches were mainly done using the PICO (Population, Intervention, Comparison, Outcome) method. In order to get fact based evidence the search was specifically narrowed down to Clinical Trials. Although I was mainly interested in research in the last five years, I did not use a cut-off date. Most searches resulted in well over 100 studies. In order to parse out the relevant articles, I would read each title; if it seemed relevant to my search I would then read the abstract. If the abstract was unclear then, I would further read the paper.Boolean terms used:Gum bleeding and oral healthGingivitis and home careGingivitis and brushingGingivitis and flossingGum bleeding and periodontal diseaseVitamin deficiency and gum bleedingIllnesses and gum bleedingMouth Breathing and gum bleedingCrowded teeth and gum bleedingMedication and gum bleedingGum bleeding and dental floss Gum bleeding and water flossGum bleeding and vitaminGum bleeding and vitamin CInitially, when starting my literature review, I planned to focus on which method reduces bleeding more, water flossing or traditional flossing. While doing the literature search, I found that the studies were very sparse and limited. I decided that my topic was too narrow and not enough research has been previously done. I broadened my search topic to, “The causes of gum bleeding and how it can be prevented”. With this topic, it seems the results and studies I found are unlimited and plentiful. I had to weed out articles that were irrelevant or too specific in order to complete my literature review. As mentioned above, there was an abundance of articles found with the searches I used. I tried to use only articles published in the last five years. There were a few older studies that were extremely important and relevant to my research. For example, the ADA released an article in 2013, “The new AAOS/ADA clinical practice guidelines on Prevention of Orthopedic Implant Infection in Patients Undergoing Dental Procedures”. (Jevsevar and Abt, 2013) This article discusses collaborative agreement between doctors and dentists on guidelines for antibiotic prophylaxis. Poor oral hygiene and gum bleedingMy goal is to be an expert on gum bleeding, the cause, the prevention and what can be done to improve and/or cure it. Gum bleeding is the most common cause of symptom of gingivitis, which is a build-up of plaque. This is generally caused by poor oral hygiene and can be easily prevented by daily brushing and flossing and a routine cleaning. Evidence of this is presented in a 72-month study on oral health prevention done on children. A quasi-experiment was run on 220 children at school, which consisted of daily brushing supervised by a teacher. Several epidemiological indices were used to “record healthy permanent teeth, health of the gums and attitude towards dental health.” Pre-and post-test were performed. The author concluded that the preventive strategies reduced the rates of bacterial and gingival plaque as well as the children had a more positive attitude towards dentistry. (Herrera, Yuliana, and Soto, 2018)In another study with 273 children over a four-year period comparing supervised and unsupervised tooth brushing it was found that the mean Visible Plaque Level (VPL) and mean Gingival Bleeding Level (GBL) were significantly lower on the pre and post-tests. (Hilgert, Bronkhorst, Frencken 2015)These are two good examples that good oral hygiene practices can reduce plaque, gingivitis and gum bleeding. This is also why it is important for patients to be educated at their recare visit on proper home care and oral hygiene instructions.Medications and gum bleedingWhen a patient comes into the office and appears to have very little plaque and demonstrates signs of good oral hygiene, with generalized bleeding on probing and scaling, the clinician must look for another cause. The bleeding and inflammation could be caused by a medication they take. For example, I have a patient who presents with good hygiene but takes synthroid for a hypothyroid. The patient’s gums bleed during the cleaning due to this medication. This is one of the many reasons it is essential to go over your patient’s health history at each and every hygiene appointment. Many medications have a side effect of xerostomia (dry mouth). When tissues are dried out they become more sensitive to gum bleeding. A few commonly taken medications are aspirin, antidepressants, antihistamines, antipsychotics and more. There are also specific medications that are known to cause significant gingival overgrowth. Some of these medications include, phenytoin (seizure medication), cyclosporine (immune-depressant drug often used to prevent transplant rejection) and many blood pressure medications. (Calcium channel blockers)Illness and gum bleedingAt one time all patients who have had hip or knee replacements were instructed to pre-medicate before they had their teeth cleaned, but this is no longer the case. According to an article in Verywell health, “The American Academy of Orthopedic Surgeons (AAOS) and the American Dental Association (ADA) had a complete turnaround in policy. In their revised guidelines, the two organizations jointly stated that antibiotics should not be considered mandatory for persons undergoing routine dental Work.” (Cluett, 2018) The key praise here is “routine dental work.” Major extractions and dental work for joint replacement patients is still appropriate. There are however several illnesses or conditions that do require pre-medication prior to a dental visit because of a weaken or abnormal immune system. These would include Rheumatoid arthritis, Lupus, Insulin-dependent diabetics, hemophiliacs, organ transplant recipients, cancer radiation therapy patients, HIV, persons who have had past infections of a joint, and patients with a cardiac condition. This is why it is important to get a good medical history on patients and update it regularly.Those suffering from Thrombocytopenia (low blood platelet count) can suffer from excessive bleeding of the gums. This is a condition where a patient’s blood cannot clot as easily. These patients may need medical clearance before continuing with any invasive dental treatment. (This includes dental cleanings). (Jevsevar and Abt, 2013)Vitamin Deficiency and Gum bleedingDiet is also a factor in oral health. Evidence suggests that the lack of calcium, vitamin C and vitamin K can lead to gingivitis and gum bleeding. This is more often found in third world countries but it is not unheard of the United States. In a study done in Sri Lankan on 784 children ranging in age from 48 to 72 months who attended pre-school, it was found that there was evidence of gingivitis bleed upon probing in 52.9% of the students. There also was evidence that “children with high daily dietary intake of calcium had less gingival bleeding on probing than those with low intake”. This study also indicated that children with gingivitis bleeding had more plaque on their teeth, their mothers were not employed or they came from families with three or more children. (Nanayakkara, Ekanayake 2014)It has been well documented that calcium plays a major role in tooth health and this research indicates that children with a daily diet of calcium are less likely to have gingivitis or bleeding.When trying to investigate whether specifically lack of vitamin C causes gingivitis and gum bleeding, there is little hard evidence. But when I opened my search to all articles not just clinical trials there were several individual case scenarios. For example:In an isolated case, it was found that a two-year-old child who was originally diagnosed with pediatric rheumatoid arthritis was ultimately determined to have scurvy due to an inadequate dietary supply of Vitamin C, with oral symptoms of gingivitis, swelling and bleeding. She was treated with vitamin C twice a day, which led to remission. (Bacci, Sivolella,?Favero, and Berengo, 2010). Another article indicated that Scurvy is back; in a study of two older men who had scurvy, caused by vitamin C deficiencies that improved significantly with treatment. This study presents a case report of 2 patients undergoing rehabilitation at Karin Grech Hospital in Malta, noted to have signs and symptoms of vitamin C deficiency. Vitamin C levels were found to be low and thus supplementation was administered. After a few weeks, a significant improvement was noted in level of frailty, mood, bleeding tendency, and gum health. The author concluded that, “The modern doctor must keep this ancient disease in mind, as it presents insidiously with debilitating repercussions, particularly in older people who are at a higher risk. It is easily treatable once detected.” (Callus, Vella and Ferry, 2018)Also, in a double-blind study of a group of 16 patients with gum disease, compared to a control group of 16, it was examined whether a mixture of micronutrients consisting of alpha-tocopherol acetate, ascorbic acid, choleclcipherol and an extract from green tea, had any effect on gum bleeding. “After 6 months, the number of gingival bleedings on probing was significantly more reduced in the experimental group when compared with the placebo group. Also, evident improvement was significantly more observed in the experimental group when compared with the placebo group.”?(Pavel and Pavel 2010)?Water flossing vs traditional flossing and gum bleedingWater flossing vs tradition flossing and gum bleeding was my original research question. After researching the literature, I found very few evidence based articles on this topic. One relevant study was a randomized, single-blind 28-day trial. The study consisted of 105 subjects, with 35 subjects randomly assigned to three groups. Group1 (N=31)-manual toothbrush and floss: Group 2(N=32)-manual toothbrush and dental water jet; and Group 3(N=32)-sonic toothbrush and dental water jet. Subjects were scored using a bleeding index, a gingival index and a plaque index at baseline, day 14 and day 28. “The results of this clinical trial indicated that when combined with manual or sonic tooth brushing oral irrigation is an effective alternative to manual tooth brushing and dental floss for reducing bleeding, gingival inflammation, and plaque removal.” (Barnes, Russell, Reinhartdt, Payne and Lyle, 2005)According to Waterpik, water flossing is definitely effective for those with braces / orthodontic treatment. “It is?clinically proven?more effective than dental floss for people with braces.” I can see how it could be more effective. I find when I have a patient with braces, using my ultrasonic scaler or piezo that gives off water helps to easily irrigate the tissues and remove food debris/plaque easier. Waterpik has done several studies which provide evidence of the effectiveness of the water flossing. In one such study, 82 subjects were randomly assigned to two groups. Waterpik Water Floss (WF) plus a manual tooth brush and Sonicare Air Floss (AF) plus a manual tooth brush. Data was evaluated for gingivitis bleeding and plaque data at baseline two weeks and four weeks and found significant differences between the two cleaning devices. The authors concluded that “The Waterpik Water Flosser is significantly more effective than Sonicare Air Floss for reducing gingivitis and plaque.” (Sharma, Lyle, Qaqish, and Schuller, 2012)In another study done by Waterpik, with 69 subjects, the authors compared the clinical signs of inflammation reduction between the Waterpik (WF) plus a manual toothbrush and the Sonicare Air Floss Pro (AFP) plus a manual toothbrush. Several indices were measured, they concluded that “The Waterpik Water Flosser is significantly more effective than the Sonicare Air Floss Pro for reducing clinical signs of inflammation.” (Goyal, Lyle, Qaqish and Schuller, 2016)It does appear that water flossing does have a positive effect on oral health, but because Waterpik has done much of the research in this field I feel a look at other water floss products should be investigated. Therefore, I googled the internet for “water pics” and found the following review on the 10 best water pics. See Figure 2.Figure 2This information was gathered by Best Review Guide on 94 reviews. This was not a scientific study and probably was linked to Amazon, but it does give a general idea of what’s out there and the opinion of those people who purchased one. The scores ranged from a high of 9.8 to 7.2 out of 10. All water picks cost between $29.99 and $42.95 with one outlier the Waterpik for $69.99. Two of the 10 (numbers 4 and 5) are approved by the American Dental Association (ADA) both the Waterpik brand. Three of the 10 (numbers 6, 7, and 10) are U.S. Food and Drug Administration (FDA) approved. It does appear the water flossing is beneficial in removing gingivitis and plaque and gum bleeding but I feel more research is needed in comparing the different brands. Somehow, Waterpik has cornered the market and gotten ADA’s approval. Mouth breathing and gum bleedingThose who have difficulty breathing through their nose, often rely on breathing from their mouth. At night, when one breaths through their mouth, they dry their gum tissue out. This can cause chronically red and inflamed gums. Because of this, this could also lead to gum bleeding. In an article written by Dr. William Meyer, he states, “A dry mouth is a dangerous mouth. Not only can a chronically dry mouth lead to bad breath and increase the risk of tooth decay and cavities, it can also put you at risk for gum disease and gingivitis. Gum disease is a serious oral health problem that has been linked to whole-body issues like heart attacks, strokes, and heart disease.” (Meyers, 2014) It is interesting that such an involuntary movement can lead to a series of health problems that could impact ones’ entire body and overall health. Certain characteristics a dental hygienist should look for when determining if someone is a mouth breather are: dry lips, crowded teeth, snoring and mouth open while sleeping, increased airway infections like sinus, ears, and colds, and chronic bad breath. If someone is unaware that they are a mouth breather or not these are good signs to look for. Crowding teeth and gum bleedingMisaligned teeth can actually do so much more than just not look “pretty”. All types of tooth malposition, such as diastemas, crowding, rotated teeth, incisor proclamation and mandibular molar tipping, may result in early tooth loss due to the formation of periodontal pockets on the mesial or distal surface of the tooth involved, because the bone crest tends to follow the cementoenamel junction. Misaligned teeth causing crowding create areas in the mouth that are difficult to keep clean. It is not the misaligned teeth alone that lead to bleeding but because they are very difficult to clean thoroughly. I find that when orthodontics such as traditional braces or Invisalign is suggested to a patient they feel that it is to improve the overall aesthetics. While aesthetics is highly improved, a main reason why dental professionals want patients to treat their crowded teeth is due to function and oral health. Bleeding gums is very common with crowded or crooked teeth but that’s not the only issue. “Crooked teeth also cause traumatic occlusion or bite wherein excess force is placed on the teeth. This can injure your teeth supporting structures (periodontium) and cause loss of bone around the teeth.” (Administration of “The Health Site, 2014). A way to reduce bleeding and the risk of gum disease would be to take action and get the teeth aligned. Pregnancy and gum bleedingPatients who are currently pregnant are more at risk to develop periodontal disease and have gum issues. Because of this, patients who are pregnant should get their teeth cleaned more frequently to avoid gum complications. These patients should in fact avoid dental visits during the first trimester. During the first trimester, the baby goes through the most growth and development of organs. There are many studies that indicate those patients who are pregnant and have periodontal disease can give birth to a low birth weight child. In one article, “Periodontal therapy and low birth weight: preliminary results from an alternative methodologic strategy”, it discusses the importance of periodontal therapy, previously known as scaling and root planning, and pregnancy. In a study of 234 pregnant women, 54 in the test group (treatment of periodontal disease), 68 in control group I (without disease), and 112 in control group II (untreated periodontal disease), the results indicated no difference in the baby’s birthweight between the test group and control group I. There was a significance difference between group II, the untreated group of those with periodontal disease. The results conclude that, “successful periodontal therapy in pregnant women suffering from periodontitis is a protective layer promoting the birth of children with normal weight”. It is beneficial for pregnant women with periodontal disease to seek periodontal therapy treatment before giving birth to their baby. (after the first trimester) (Gomes-Filho, Cruz, and Costa, 2010)In another study to determine whether in vitro-fertilization (IVF), has an effect on the women’s preexisting periodontal status, and if that status has an impact on IVF. In this study, sixty women were recruited, and the following tests were performed before and after: Gingival inflammation (simplified gingival index, GI-S), plaque levels (plaque control record index, PCR), and bleeding on probing (BOP). It was concluded that, “periodontal clinical parameters worsened in women undergoing IVF treatment”. (Pavlatou, Tsami, Vlahos, Mantzavinos and Vrotsos, 2010) From these studies, it is evident that there is a correlation between a women’s body and periodontal pathogens. Women looking to conceive or are pregnant should make sure their oral health is adequate and taken care of. Periodontal therapy (scaling and root planning) and gum bleedingA patient who comes into the office with excessive bleeding and subgingival calculus should be properly treated with nonsurgical periodontal therapy. Nonsurgical periodontal therapy is completed by a registered dental hygienist. The patient receives local anesthetic to numb the tissue. Once the tissues are numbed, the hygienist will use the hand-held instruments in combination with a piezo or ultrasonic scalers, to go beneath the gum line to break up the bacteria and remove it. This could be done quadrant by quadrant (1 hour each) or in my office we typically do 2 quadrants in an hour and a half. This process will help remove bacteria from the oral cavity and reduce the pocketing, inflammation and gum bleeding. At my office, the dentist and I worked together to implement a periodontal program. The program includes scaling of all four quadrants, a Sonicare electric toothbrush and a visit in 4-6 weeks for periodontal maintenance. At the maintenance visit, we re-perio chart, go through the entire mouth and clean it up and really address home care and management for this patient. After this visit, we like to see our patient back in 3 months to see how they are maintaining. When patients don’t want to come back that soon we kindly, explain that periodontal therapy is a huge investment of time and money and we want to keep them on track. A study written by the ADA concludes that, “clinicians should consider SRP as the initial treatment for patients with chronic periodontitis” (ADA News Releases, 2015)Discussion / ConclusionWhen a patient comes into my chair and I start cleaning their teeth and see profuse bleeding, it is my responsibility to evaluate the patient as a whole. Just because the most common connection between bleeding gums is with poor oral hygiene, it is the health care professionals job to make a dental hygiene diagnosis. After going through studies on end, I can conclude that there are many possibilities that can lead to gum bleeding. This is why it is essential to review a patient’s medical history at each and every hygiene visit. The patient could have had a medical issue such as a joint replacement. This may or may not require pre-medication. The patient could be taking a certain medication or recently diagnosed with an illness that could lead to bleeding gums. The patient may have a vitamin deficiency resulting in scurvy which could be the cause of bleeding. It has been shown that a simple course of vitamin C can correct this. It has been shown that water flossing is very beneficial for oral health. The patient could be pregnant or breastfeeding and those excessive hormones can cause gum bleeding. Also mouth breathing and crowding teeth could cause gum bleeding. After evaluating the patients mouth and tooth anatomy, one must look to see if the misalignment or crowding is causing inflammation and bleeding. All in all, there are many factors that could lead to bleeding gums. This is also why comprehensive care and individualized treatment planning are so important to creating overall health for a patient. I have found that there are certain methods to help reduce bleeding gums. For one, I find that my patients who use electric toothbrushes have significantly healthier gums then those who don’t. More than half of my patients (15 out of 23) in my survey used an electric toothbrush. I am also very fond of the rubber tip stimulator, which works to massage the tissue and reduce inflammation. If a patient presents with braces, a bridge or implants, I always highly encourage the use of a water flosser. I find that the oral irrigation is super beneficial to these patients and helps remove food debris, plaque, and bacteria that is often trapped in these areas. Even though the Waterpik is the only one recommended by the ADA, there are several other water flossers on the market that could do the job. Every person is different, something that works for one may not work for another. These are adjuncts that I personally find to work very well when discussing oral hygiene instructions and home care with patients. To conclude, every single patient who walks into the door is different and needs to be treated with individualized care. The biggest problem I feel is that patients are uneducated on bleeding gums – what causes it and how is it prevented. I have numerous patients say to me daily, “my gums always bleed” or “its normal for my gums to bleed”. The purpose of this paper and literature review is to disuses that healthy gums do not bleed. There is an abundance of different factors that could lead to bleeding and many different methods to use to reduce bleeding. Bleeding gums can be reduced or eliminated and can in turn lead to a healthier oral cavity. Every patient’s genetic, medical history, and anatomy should be taken into consideration when diagnosing bleeding gums. Appendix 1.Raw Data of Dental Hygiene Survey????Pt ## monthsGums BleedUse at HomeTimes A DaySexAge Range16ya,d2m424nb,c,d2f436na,c,d2f448ya,d1-2f453nb,d2-3m364ya,e,f2m473nb,c,e,f2f486na,d,f2f493ya,d,f2f3105nb,c,d2f3116nb,d2-3m4124yb,f1-2m41312ya2m4146nb,e2f2156na,d2m2166nb,d,f2f3176yb2f4183nb,d,f1-2m4193nb,c,f2f3204nb,d2f2216nb,d2m4226nb,d2f4239na,d2m3246nb2f42518ya1-2m4ReferencesADA News Releases, 2015, ADA Statement: New CDC Statistics Show Need for Increased Access to Dental Care, with a Greater Emphasis on Preventing Disease, ADA News Releases,12 May.Admin. How Crooked Teeth May Cause Gum Disease. , 14 Jan. 2014, oral-health/how-crooked-teeth-may-cause-gum-disease/.Bacci, C., Sivolella, S., Pellegrini, J., Favero, L., and Beregno, M., 2010. A rare case of scurvy in an otherwise healthy child: diagnosis through oral signs. Pediatr Dent; Nov-Dec, 32(7):536-8. PubMed ID: 21462768Barnes, C.M., Russell, C.M., Reinhartdt, R.A. Payne, J.B., and Lyle, D.M., 2005. Comparison of Irrigation to floss as an adjunct to tooth brushing: effect on bleeding, gingivitis, and supragingival plaque., J Clin Den, 16(3):71-7.Callus, A.C., Vella, S. and Ferry, P., 2018. Scurvy Is Back, Nutr Metab Insights, journals.doi/full/10.1177/11B78638818809097. PubMed ID: 30479485Cluett, J.. 2018. Are Antibiotics Needed for Dental Work After a Joint Replacement??VerywellHealth, antibiotics-before-dental-work-2549523.Frank, C., 2017, Gum Disease (Gingivitis), Healthline ,A Medically Reviewed, , L.H., Lin, Z.K., Guo, Q., Ni. J., Qian, J.L., Shu, R., (2017). Survey of Periodontal Health inMedical College Students after 3 Years of Periodontal Health Maintenance.?Shanghai Kou Qiang Yi Xue = Shanghai Journal of Stomatology, U.S. National Library of Medicine, Aug.Gomes-Filho, II.S., Cruz, S.S., Costa Mada, C., Passos, J.S. Cerqueira, E.M. Sampaio, F.P., Pereira, E.C. and Miranda, L.F., 2010, Periodontal Therapy and Low Birth Weight: Preliminary Results from an Alternative Methodologic Strategy. Journal of Periodontology, U.S. National Library of Medicine, Dec.; 81(12):1725.33, ncbi.nlm.pubmed/20653439.Goyal, C.R., Lyle, D.M., Qaqish, J.G. and Schuller, R., 2015, Efficacy of Two Interdental Cleaning Devices on Clinical Signs of InFlammation: A Four-Week Randomized Controlled Trial. J Clin Dent: 26(2):55-60. PubMed ID: 26349127.Hilgert, L., Bronkhorst, E.M., Leal, S.C. and Frencken, J.E., 2018. Long-term Effect of Supervised Toothbrushing on Levels of Plaque and Bleeding Among Schoolchildren. 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