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Acute myeloid leukemia with oral manifestations: Case report and brief
overview

Article · January 2008

DOI: 10.4103/0972-1363.44370

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Kruthika Guttal Krishna Burde

SDM College of Dental Sciences and Hospital SDM College of Dental Sciences and Hospital
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 Case Report

Acute myeloid leukemia with oral manifestations: Case

report and brief overview
Kruthika S. Guttal, Venkatesh G. Naikmasur, Krishna N. Burde, Akhil C. Deka1
Department of Oral Medicine and Radiology, SDM College of Dental Sciences, Sattur, Dharwad-580 009, Karnataka, India, 1Karnataka
Cancer Hospital and Research Centre, Navnagar Hubli, Karnataka, India

Abstract
Many systemic diseases do manifest in the oral cavity. Leukemia is one such hematological disorder presenting with varied clinical
and oral manifestations. Presented here is a case of gingival hyperplasia heralding the presence of acute myeloid leukemia and brief
overview of the condition.

Key words: Acute myeloid leukemia, gingival hyperplasia, leukemia

Introduction
Leukemias are considered to be potentially lethal diseases
in which there is neoplastic proliferation of bone marrow
white blood cells.[1] The etiology of this condition ranges
from exposure to ionizing radiation or chemical to genetic
predisposition (Down’s syndrome).
They can be categorized based on clinical course as acute and
chronic and on cell of origin as lymphoblastic or myelocytic
(non-lymphoblastic) types. The general manifestations of
leukemias include anemia, thrombocytopenia, susceptibility
to infections and lymphadenopathy.[1] All these features
are secondary to infiltration of the blood, bone marrow
and other tissues by neoplastic cells of the hematopoietic
system.
Presented here, is a report of a case of acute myeloid
leukemia (AML) with oral manifestations, general treatment
outline and dental management of such patients.
Case Report
A 40-year-old female patient reported to our hospital
with the chief complaint of swollen gums of one-month
duration. The enlargement of the gums was gradual in
onset, associated with intermittent bleeding on chewing
and while brushing the teeth. Patient also gave history of
inability to maintain oral hygiene and difficulty in chewing
secondary to enlargement. There was history of intermittent
fever since 10 days. There was no positive history of similar
gingival enlargement in her family. Her medical history was
unremarkable and furthermore patient was not on any long-
term medications for any illnesses. Her general examination
revealed pallor of the lower palpebral conjunctiva, nail beds
and the patient was febrile. Intraoral examination revealed
pallor of gingiva with loss of normal contour and stippling.
Also apparent was generalized diffuse enlargement of
marginal, attached gingivae and of interdental papilla, both
on buccal, lingual and palatal aspects of all the teeth [Figure
1]. The enlargement was extending up to to incisal third of
anterior teeth and occlusal thirds of post teeth [Figure 2].
There was also evidence of interspersed areas of erythema
which were multifocal on the buccal aspect of lower left
premolars. The gingiva was soft-firm in consistency and
tender on palpation. There was no pus discharge on digital
pressure. Bleeding was elicited on gentle probing of the
gingival sulcus.
Provisional diagnosis
The previous hematological reports of the patient were
inconclusive and revealed only increase in total leukocyte
count to be 98,800. Based on clinical features and the
report, the gingival enlargement was presumed to be
secondary to leukemia.

Correspondence: Kruthika S. Guttal, Investigations

Department of Oral Medicine and Radiology, SDM College of Dental
Sciences and Hospital, Dharwad 580 009, Karnataka, India. As a part of further investigations, heamatological tests were
E-mail: drkruthika@yahoo.co.in advised. Reports revealed the red blood cells counts to be

30 Journal of Indian Academy of Oral Medicine and Radiology / April - June 2008 / Volume 20 / Issue 2
 Guttal, et al.: Gingival enlargement in AML
Figure 1: Generalized diffuse gingival enlargement
2.96 million/cu mm, Hb% was 9.5gm%, total white blood
cells count was 1,50,000 cells/cu mm and platelet count was
65,000/cu mm. The differential count was 96% blast cells,
3% mature neutrophils and 1% basophils. The blast cells
were of myelocytic type. All the features were suggestive of
acute myelocytic leukemia.
Treatment
Patient was referred to Karnataka Cancer Hospital for
treatment. Chemotherapy was planned for the patient.
The patient failed to report for the treatment and also for
the follow up. Dental treatment was also deferred till the
treatment was completed but the patient did not report
back to our unit.
Discussion
AML results from abnormal proliferation and differentiation
of hemopoietic progenitor cells. [2] The cells fail to
differentiate and then proliferate uncontrollably. The
immature myeloid or blast cells accumulate and replace
bone marrow,[2] implying manifestations to be marrow
failure and cytopenia.[3]
The incidence of AML increases with age, with peak in the
6th decade.[2] It is believed that less than half of the cases
occur in patients younger than 50 years.[2]
The oral manifestations develop in 65-90% of cases which
ranges from lymph node enlargement, pallor, purpura
or bleeding from gingivae, candidal or viral infection,
oral ulceration, gingival swelling (secondary to leukemic
infiltrate).[1]
Gingival swelling is seen in 20-30% of patients with AML[1]
this results from an abnormal response to dental plaque
Journal of Indian Academy of Oral Medicine and Radiology / April - June 2008 / Volume 20 / Issue 2
Figure 2: Enlarged gingival extending upto incisal third of anterior teeth
and occlusal thirds of posterior teeth
causing distension of tissues by dysfunctional white cells.
Gingival hyperplasia is characterized by progressive
enlargement of the interdental papillae as well as the
marginal and gingiva.[4] Gingiva appear swollen, devoid
of stippling and pale red to deep purple in color.[4] Also
observed are mucosal hemorrhages, ulcerative gingivitis,
infectious gingivitis and odontalgia.[4] Gingival hyperplasia
is more common in acute than chronic leukemia, in adults
and in people with “aleukemia” or “subleukemic” forms of
leukemic. Leukemic cell gingival infiltrate is not observed
in edentulous individuals, suggesting that local irritation
and trauma associated with the presence of teeth may play
a role in the pathogenesis of this abnormality. In general,
gingival hyperplasia resolves completely or partly with
effective leukemia chemotherapy.[4]
Dental management of patients with leukemia can often
be complicated by bleeding tendencies and susceptibility
to infection. There is increased risk of septicemia from oral
infections as they are immunocompromised.
General guidelines for oral health care for patients with
leukemia have been outlined in Table 1.[1]
Traditional therapy for AML includes remission induction
and post remission therapy. [2] The goal of remission
induction is to reduce the number of leukemic cells below
clinical detection allowing normal hematopoiesis[3] but the
disadvantages of traditional form of therapy is that it causes
severe myelosuppression. Combination of mitoxantrone,
idirubicin or daunorubicin is included in the standard
regimen to achieve remission.[2] Post remission treatment
may also include hemotopoietic stem cell (HCT) transfusion.
This involves high doses of chemotherapy and occasionally
total body radiation followed by transplantation of normal
stem cells. Patient’s stem cells are collected in remission and
31
 Guttal, et al.: Gingival enlargement in AML
Table 1: Guidelines for dental management during various
phases of treatment
Prechemotherapy Assessment of oral health, with
appropriate treatment plan
Extraction of non-restorable teeth
Restoration of decayed teeth with fluoride
prophylaxis
Chlorhexidine prophylaxis
Induction chemotherapy Preventive oral health care
Antifungal and antiviral prophylaxis
During remission Continue preventive oral hygiene care
Long-term follow up Oral health care and monitor craniofacial
and dental development
cryopreserved, which may be used for autologous HCT, in
essence to rescue a patient from the myeloablative effects
of high dose chemotherapy and/or radiation therapy.[2]
Post remission treatment options include short-term
intensive consolidation chemotherapy or high dose
myeloablative chemotherapy with or without radiotherapy
combined with bone marrow transplant.[2]
The complications occurring during AML therapy range
from initial erythema of oral mucosa which eventually
ulcerates to form oral mucositis (7-10 days of start of
treatment). These debilitating lesions may take two weeks
or more to resolve and may become superinfected with
bacteria, viruses or fungi. Acute odontogenic infections may
complicate myeloablative chemotherapy of HCT. Therefore
appropriate pretreatment planning is essential.[2] In addition
patients who have undergone an allogenic HCT may also
develop oral lesions related to Graft Versus Host Disease.
If the patient’s condition mandates extraction during the
chemotherapy regimen lab analysis of neutrophils and
platelet counts remains highly essential.[2] Ideally the
absolute neutrophil count should be greater than 1000/
ml and platelet count of at least 60,000/ml are considered
acceptable for oral surgery in addition the counts should
be anticipated to remain stable for 14 days.
Despite the availability of range of treatment modalities,
AML is still associated with significant morbidity and
mortality. The disease per se or the treatment can have oral
manifestations. Special attention has to be paid during the
pretreatment dental evaluation and followed by preventive
oral health care during post treatment phase.
Acknowledgments
The authors would like to acknowledge Dr. C. Bharsker Rao,
Principal, SDM Dental College Dharwad.
References
1. Scully C, Cawson RA. Medical problems in dentistry. 5th ed. New
Delhi: Churchill Livingston; p. 156-60.
2. Parisi E, Draznin J, Stoopler E, Schuster SJ, Porter D, Sollecito TP.
Acute myelogenous leukemia: Advances and limitations of treatment.
Oral Pathol Oral Radiol Endod 2002;93:257-63.
3. McKenna SJ. Leukemia. Oral Pathol Oral Radiol Endod
2000;89:137-9.
4. Cooper CL, Loewen R, Shore T. Gingival hyperplasia complicating
acute myelomonocytic leukemia. J Can Dent Assoc 2000;66:78-9.
Source of Support: Nil, Conflict of Interest: Nil

32 Journal of Indian Academy of Oral Medicine and Radiology / April - June 2008 / Volume 20 / Issue 2

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