Hemorrhage may occur during treatment-induced thrombocytopenia and/or coagulopathy and is a concern for patients receiving high-dose chemotherapy or undergoing hematopoietic stem cell transplantation.[1] Spontaneous gingival oozing may occur when platelet counts diminish to less than 30,000/mm³, especially when there is preexisting gingivitis or periodontitis. Even normal function or routine oral hygiene (brushing and flossing) can induce gingival oozing in the face of preexisting gingivitis and periodontitis. Although rarely serious, oral bleeds can be of concern to nonexperienced individuals such as the patient and family. Oral bleeding may be mild (e.g., petechiae located on the lips, soft palate, or floor of the mouth) or severe (e.g., persistent gingival hemorrhage or bleeding from herpes simplex virus (HSV) ulcers in the face of severe thrombocytopenia).

It is not uncommon for oncology patients to be told specifically to not use toothbrushes and dental floss when platelet counts drop below 40,000/mm³. This is generally poorly advised unless there are extenuating circumstances. Healthy gingival tissues do not bleed unless traumatized. Discontinuation of routine oral hygiene can increase the risk of infection that could not only promote bleeding, but also increase the risk of local and systemic infection due to accumulation of bacterial plaque, leading to periodontal infections and tissue breakdown. This further supports the utility of precancer therapy dental treatments to reduce or eliminate gingival or periodontal conditions. The degree of health professional oversight of thrombocytopenic patients is an important consideration relative to risk of mechanical hygiene procedures; with comprehensive monitoring, patients can often safely use dental brushing and flossing throughout the thrombocytopenic episode. While the use of foam brushes is often promoted to reduce the risk of bleeding, this is usually ill-advised. Studies have shown that foam brushes cannot adequately remove dental plaque along gingival margins, thus promoting gingival infection and bleeding.

Management of oral bleeds revolves around the use of vasoconstrictors, clot forming agents, and tissue protectants. Epinephrine or cocaine can be used topically to reduce blood flow rates through bleeding vessels. Topical thrombin and/or hemostatic collagen agents can be used to organize and stabilize clots. Application of mucosal adherent products (including cyanoacrylate products) help seal bleeding sites and protect organized clots. Patients who tend to form friable and easily dislodged clots will benefit from topical application of aminocaproic acid; in some instances, intravenous administration can be considered to improve coagulation and the formation of stable clots.

Application of 3% hydrogen peroxide and 0.9% saline (1:2 to 1:3 by volume) can aid in wound cleansing and removal of superficial blood debris. Care must be taken not to disturb clots, which might promote bleeding.[2]

References

1. Schubert MM, Peterson DE, Lloid ME: Oral complications. In: Thomas ED, Blume KG, Forman SJ, eds.: Hematopoietic Cell Transplantation. 2nd ed. Malden, Mass: Blackwell Science Inc, 1999, pp 751-63. 
   
   
2. Schubert MM, Peterson DE, Lloid ME: Oral complications. In: Blume KG, Forman SJ, Applebaum FR, eds.: Thomas' Hematopoietic Cell Transplantation. 3rd ed. Malden, Mass: Blackwell Science Inc, 2004, pp 911-28.