Mouth bleeds in bleeding disorders

GRAINNE DUNNE

Grainne Dunne is Clinical Nurse Consultant, Haemophilia, at Sydney Children’s Hospital

Our mouth is a most wonderful and interesting part of our body. It’s the first step in breaking down food to allow us to then to swallow our food; we taste everything using our mouth; it’s important in the process of breathing; we communicate with our mouths to talk, smile, show emotions; and it’s an important way to show our loved ones how we care about them with that simple but important kiss.

However, it’s also highly vascular…. which means it has many, many blood vessels that are needed to perform all the above amazing functions. When you have a bleeding disorder of any type (haemophilia, von Willebrand disease, inherited platelet function disorder or another rare bleeding disorder), injury to these blood vessels can lead to a lot of blood loss and at times can be challenging to stop.

SO WHY CAN MOUTH BLEEDS BE TRICKY TO STOP?

1. As this is a highly vascular area, there are a lot of blood vessels to leak out blood when injured.

2. Saliva in the mouth, required to break down food and to keep our mucus membranes becoming too dry, contains enzymes and uric acid. These elements are not good friends with a newly developing clot, particularly in a bleeding disorder when the clot is difficult to make to begin with. Saliva can play a part in breaking down a weak clot which leads to the initial injury site re-bleeding again.

3. Chewing and movement of food around the mouth, particularly hard or bulky foods, can knock at and disturb a developing clot and thus restart the initial bleed again. 

4. Humans are curious by nature. When we feel something unusual in our mouth, we naturally want to investigate it. In fact, for many of us, it’s difficult to consciously leave it alone. So, whether consciously or subconsciously, we often push our tongue over the injury site to ‘examine/investigate’ that unusual feeling in our mouth. In some cases, it may be an over-curious finger that finds its way into our mouth investigating that tender injury site – especially in children. Such ‘examination’ or ‘investigation’ can disturb a tender and developing clot and of course… restart the bleed.

5. Objects in the mouth: In young toddlers and babies, toys and other objects are notorious for finding their way into the mouth. A child at this age often uses their mouth to investigate an object – which is not what one wants when a clot is trying to form and harden after a bleed has recently occurred. The older and more mature child (and adult!) can accidently hit the injury site using their eating utensil e.g., fork, spoon, and again disturb the delicate clot development.

FIRST AID FOR MOUTH BLEEDS

Ice! It’s simple but its effective.

• If ice is not available, try rinsing/gargling with very cold water. Icy poles can be offered to children as a friendly and co-operative form of ice. It also helps to extend the time for which ice can be kept in their mouth. It often acts as a calming soother too after an injury has occurred.You can apply pressure to the area with a gauze – however, this isn’t usually well received in children. An icy pole (or plain ice if tolerated) will be more effective!

When does a mouth bleed need medical help?

• When the bleed is continuous for longer than 15-30 minutes. Discuss this also with your local Haemophilia Treatment Centre. Sometimes this time plan may need an individualised approach.If the bleed can be stopped with first aid but restarts again and then continues to stop and start. If unsure what to do, call your local Haemophilia Treatment Centre for advice.If vomiting occurs. This usually means that too much blood has been swallowed (and hence lost), which has irritated the stomach to initiate vomiting.

Blood loss from the mouth can be difficult to measure, especially if it stops and starts over a period of hours or days. One can easily underestimate the total volume of blood lost and may later be surprised to discover a significant drop in the patient’s haemoglobin level i.e., what the body uses to carry oxygen around the body. In fact, some people have had their first hospital presentation and bleeding disorder diagnosis made with a history like this…. including a significantly low haemoglobin.If you are unsure about mouth bleeding, please do not hesitate to contact your local Haemophilia Treatment Centre at the time.

Do I need to tell my haematologist that I am having mouth surgery? 

YES!

• If you or your child require any surgery in the mouth, however small, contact your local Haemophilia Treatment Centre. This is necessary for both urgent and non-urgent procedures. It’s very possible that surgery will need to be performed with factor replacement therapy or FFP/ platelets and supervision by your haematology team.

• Inform your surgeon that you or your child have a bleeding disorder and that consultation with your haematologist is necessary in advance of any surgery.

• Inform your dentist if any dental surgery is required, e.g., dental extraction, cutting of the gum. Routine check-ups and teeth cleaning are generally safe without needing factor/FFP/platelets.

DENTAL HYGIENE

Prevention is always better than cure!Dental plaque is a sticky, acidic film of bacteria and food debris on teeth, which everyone gets – it’s a normal process. However, a build-up of plaque is bad for your teeth and if not removed will form tartar.  Plaque and tartar increase your risk for dental cavities, tooth decay, gum disease, reseeding gums, and other harmful dental problems, leading to tooth loss and then the need for dental surgery. 

• Ensure you brush your teeth regularly at least twice a day, and floss. See your dentist 6-monthly for routine check-ups and cleaning. Cleaning removes plaque and tartar which consequently reduces the risk for cavities, gum disease and other harmful problems.

To help between dental visits, you can remove some tartar at home. Here are a few tips.

• Baking soda: add a teaspoon of baking soda to your usual toothpaste, brush as usual and rinse with lukewarm water afterwards. Repeat twice weekly.White vinegar mouth wash: add 2 teaspoons of white vinegar to ½ cup of water and ½ teaspoon salt. Stir well, then gargle and spit. Use twice daily to rinse your mouth.Over the counter antibacterial mouth wash.

FURTHER READING

Australian Haemophilia Centre Directors’ Organisation. A consensus statement on the dental treatment of patients with inherited bleeding disorders, July 2010. Accessed 7 August 2023.HealthDirect – Dental care