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224]

Case Report

Acute myelomonocytic leukemia

presenting with gingival enlargement
as the only clinical manifestation
Lilian Menezes, Jyoti R. Rao

Department of Abstract:
Periodontics, A 34 year old woman reported for evaluation of generalized gingival swelling pain and bleeding. The patient also
Government Dental reported menstrual irregularities. Based on the oral and systemic examinations and hematological investigations,
College and Hospital, a provisional diagnosis of ‘menstrual cycle associated gingivitis’ was made. The patient was referred for a
Bambolim, Goa, India gynecologic consultation. At the three‑week dental recall, a worsening of gingival overgrowth with a necrotic
component was noted. The hematologic investigations revealed markedly elevated leukocyte counts. The clinical
and hematological findings led us to a diagnosis of leukemia.This report emphasizes the importance of the dentist
as well as the physician (in this case, the gynecologist) in correlating the oral, systemic and hematological findings
in the diagnosis and also of regular recall in the management of a case.
Key words:
Gingival enlargement, leukemia, neoplastic

INTRODUCTION changes accompanying the acute stage of this

disease were not present.

L
Access this article online eukemia is a heterogeneous group of
Website: hematological disorders that are characterized
www.jisponline.com
by disordered differentiation and proliferation
DOI: of neoplastic hematopoietic stem cells and the
10.4103/0972-124X.106926
diffuse replacement of the bone marrow by
Quick Response Code: these cells.
Thus, there is a diminished production of
normal erythrocytes, causing anemia, weakness,
fatigue, and pallor; granulocytes causing
granulocytopenia, fever, and infection; and
platelets causing thrombocytopenia, bleeding,
petechiae, and bruising. Leukemic cells may
also infiltrate spleen, lymph nodes, the central
nervous system, skin, gingiva and other tissues
throughout the body.[1]
Most frequent oral finding in leukemia is
erythematous or cyanotic gingival hyperplasia
with or without necrosis, petechiae, ecchymosis,
mucosal ulcers and hemorrhage.[2,3]
Address for
correspondence:
In 1936, Love reported the pathologic changes
Dr. Lilian Menezes, in 82 patients with leukemia and suggested
Department of that oral lesions appeared to be a diagnostic
Periodontics, Government indicator for leukemia.[4] The gingival findings
Dental College and may be partially dependant on the inflammatory
Hospital, Bambolim, condition of the tissues.[5]
Goa ‑ 403 202, India.
E‑mail: applegate2k@
yahoo.com
This article reports a case of Acute
Myelomonocytic Leukemia (AML) diagnosed
Submission: 02‑09‑2011 following laboratory studies initiated solely due
Accepted: 20-08-2012 to gingival hyperplasia as the classic systemic
CASE REPORT
A 34‑year‑old female of Asian Indian origin
reported to the Department of Periodontology,
Goa Dental College and Hospital on 23rd February,
2011, with the chief complaint of swelling, pain,
and bleeding of the maxillary and mandibular
gingiva. These symptoms had been present for
about 15 days. The patient had been in good
health until the last two weeks at which time
she began to notice gingival swelling, pain, and
bleeding which grew progressively worse, which
was why she sought dental treatment.
On oral examination, the gingiva appeared
enlarged, smooth, shiny, edematous, and lacked
stippling [Figure 1a-c]. According to the patient,
she was also having menstrual irregularities for
the past 3 months and experienced excessive
tiredness ever since.
There was no evidence of lymphadenopathy,
hepatospleenomegaly, cutaneous bruising, or
petechiae.
The patient was not taking any medications. She
indicated no family history of hematological
disease in her parents or siblings.
A routine blood investigation revealed a total
leukocyte count of 10,000 cells/cmm and
Hemoglobin count of 10 mg/dl.

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Menezes and Rao: Acute myleomonocytic leukemia with gingival enlargement

A provisional diagnosis of ‘Menstrual cycle – associated
gingivitis’[6] was made. Routine scaling, root planing and pocket
irrigation were performed and the patient was referred to the
Department of Obstetrics and Gynecology at the Goa Medical
College and Hospital for consultation regarding her menstrual
irregularities. She was prescribed oral androgenic steroids
(Medroxyprogesterone, 30 mg/day to be gradually tapered
to 10 mg/day) over a period of 3 weeks.
At the 3 week dental recall, her menstruation had
regularized but the gingival swelling, bleeding, and pain
did not improve; rather the gingival swelling seemed to
worsen [Figure 2a]. Furthermore, necrosis along the gingival
margins of the maxillary and mandibular teeth was noted
[Figure 2b and c]. The patient also informed that she had
fever of 102o F for the last two days before the follow‑up
visit.

a a

b
b

c c
Figure 1: Frontal view of the gingival inflammation and overgrowth at first visit. (b) Figure 2: Frontal view of the increase in the gingival overgrowth 3 weeks after initial
Mandibular occlusal and (c) Maxillary occlusal view of the gingival overgrowth at presentation. (b) Mandibular occlusal and (c) Maxillary occlusal view of the necrotic
first visit component of the gingival overgrowth

598 Journal of Indian Society of Periodontology - Vol 16, Issue 4, Oct-Dec 2012
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Menezes and Rao: Acute myleomonocytic leukemia with gingival enlargement

Multiple soft and tender lymph nodes ranging from

1.0‑1.5 cm in diameter were palpable bilaterally in the neck as
well as axillae. A routine blood count revealed leukocytosis
white blood cell (WBC) count, 58,000/cmm and anemia (HBG
6 g/dl) suggesting an acute leukemia and the patient were
referred to Department of Medicine, Goa Medical College
and Hospital. She was subsequently admitted to a ward on
16th March 2011.

The laboratory examination the following day included

complete blood count and differential count for classification
of the WBC. A complete battery of laboratory tests, including
glucose tolerance, blood chemistry and urine analysis showed
results within normal limits. Her routine blood count at this
time revealed leukocytosis, anemia and thrombocytopenia
[Table 1].
a
The leukocyte differential count displayed 6% neutrophils,
31% monocytoid cells, 3% lymphocytes, 48% blast form, 4%
myelocytes, and 8% stabs. The peripheral smear displayed
mostly immature monocytes as well as some myeloblasts.
A diagnosis of AML ‑ FAB classification M4[7] was made.
Subsequent bone marrow biopsy revealed 90% hypercellularity.

During the hospital stay, the patient was given symptomatic

and supportive treatment, which included chemotherapy,
whole blood transfusion and antibiotics. The patient underwent
an induction regimen consisting of intravenous administration
of cytosine arabinoside (ARA‑C, 100/m2/day × 7 days) and
idarubicin hydrochloride (Idamycin, 12mg/m2/day × 3 days).
The patient tolerated the chemotherapy with minimal
complications.

The oral hygiene instructions consisted of gentle brushing and b

mouth rinsing with chlorhexidine 0.2% twice daily.

The general condition and primary gingival enlargement

of leukemic infiltration were well controlled in that, the
enlargement although persistent, was non‑progressive, firm
and devoid of its necrotic component [Figure 3a-c].

The patient was discharged with a WBC count of 7,500/cmm

and hemoglobin 8 gm/dl.

Routine dental treatment included cautious debridement of

plaque and food debris followed by chlorhexidine irrigation
every fortnight.

Unfortunately, approximately 4 months after the initial

symptoms, a recurrence of the leukemia with sepsis resulted c
in the patient’s death on 5th June 2011. Figure 3: (a) Reduction in the inflammation and no increase in the gingival
enlargement after the chemotherapy. (b and c) Resolution of the necrotic
component of the gingival overgrowth: Maxilla and mandible
DISCUSSION
Table 1: Hematological findings
The recognition of gingival enlargement as an initial oral
Test Reported value Normal value in females
manifestation of leukemic infiltration assumes great importance,
particularly in the early diagnosis of myelomonocytic WBC (× 103/ cmm) 90 4.8-10.5
RBC (× 106/ cmm) 2.04 3.5-4.5
leukemia.[8‑10] Forkner has concluded that the oral manifestation
Hb (g/dl) 6 12-16
of marked swelling, particularly in the gingiva, can usually HCT (%) 15.2 42-52
be regarded as a characteristic typical of acute monocytic PLT (× 103/ cmm) 20 140-440
leukemia, while it is usually absent in acute leukemia of the WBC – White blood cells; RBC – Red blood cells; HB – Hemoglobin;
myelogenous or lymphatic varieties.[8,11] Osgood reviewed HCT – Hematocrit; PLT – Platelets

Journal of Indian Society of Periodontology - Vol 16, Issue 4, Oct-Dec 2012 599
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Menezes and Rao: Acute myleomonocytic leukemia with gingival enlargement
127 cases of monocytic leukemia, and found that swelling of
the gingiva took place in 53% of the patients.[12] Furthermore,
Kaufman [13] reported 35% of 40 patients and Berkheiser
reported 52% of 29 patients with monocytic leukemia having
gingival swelling respectively.
Stafford et al.[14] evaluated 500 leukemic patients and found 65%
had some oral manifestation that caused them to seek care. In
fact, oral manifestations are often the first indications of disease.
Although physicians most commonly diagnose leukemia,
dentists have been responsible for initiating the diagnosis in
25% patients with acute myelogenous leukemia and 33% of
patients with AML.[14] Thus, the dental practitioner should have
an awareness of diagnostic signs and complications associated
with leukemia to better aid in diagnosis, subsequent treatment,
and management.
Of interest is the high frequency of primary gingival
enlargement as an early and only manifestation of leukemia.
This emphasizes the importance of the initial diagnosis of
myelomonocytic leukemia in the present case.
The lack of reported incidence of gingival hyperplasia in
edentulous patients led to the hypothesis that local irritants
related to teeth and periodontium promoted and acted as
cofactors in the development of gingival infiltration by
leukemic cells.[15] However, gingival hyperplasia occurs in
patients with excellent oral hygiene, indicating that local
factors are not required to promote or induce local infiltration
of oral tissues.[9] Sinrod[16] and Boggs et al.[10] also indicated that
gingival enlargement might be due to leukemic infiltration
or a secondary inflammatory response to local irritation of
preexisting periodontal disease, or both. In the present case,
it was not possible to take a gingival biopsy as the leukocyte
counts of the patient were high. Furthermore, Williams et al.[1]
reported that gingival infiltration represents a 5% frequency
as the initial presenting complication of AML.
In 1986, Barrett [17] explained the selective infiltration
of gingival tissues as being due in part to the inherent
extravascular infiltrative properties of the leukemic cell,
and in part due to the unique gingival microanatomy.
Furthermore, Dreizen et al.[9] reported that both the apparent
acceleration in the mitotic rate and the absolute number of
leukemic cells are key factors in initiating this infiltration.
While these concepts have contributed to our understanding
of leukemic cell infiltration of the gingiva, the precise
mechanisms remain elusive.
In the present case, the initial diagnosis of ‘Menstrual
cycle – associated gingivitis’[6] was made as the hematological
picture did not compel us to look for alternative causes of the
gingival inflammation and enlargement. The blood counts
changed rather dramatically within a short period of 3 weeks.
As in the present case, marked gingival enlargement occurred
within 3 weeks, vividly revealing the predisposition of gingival
tissues to leukemic cell infiltration when other possible causes
of gingival enlargement are not found. Here, it is prudent to
emphasize the importance of regular recall and follow up even
in seemingly simple cases. Following chemotherapy, WBC count
decreased gradually to 7,200/cmm. Although the enlargement
persisted, it did not progress and was devoid of its inflammatory
600 Journal of Indian Society of Periodontology - Vol 16, Issue 4, Oct-Dec 2012
and necrotic component. Based on these observations, it appears
that leukemic cell infiltration was the major cause of the sudden
onset of gingival enlargement,[9,11,15] thereby excluding other
systemic causes, local irritants, or trauma.
CONCLUSION
AML often has oral manifestations as its first indication
of the disease, [14] which is what compels them to seek
dental care. Hence, dentists are responsible for initiating
the diagnosis in 25‑33% of patients with AML. [18] Early
diagnosis and treatment can improve the patients’ chances for
remission. Thus, the professional (dental as well as medical)
who maintains a high degree of suspicion of unusual oral
conditions can play an important role in the prompt referral
and treatment of these patients. In this case, the gynecologist
was in a unique position to aid in diagnosis by suspecting
and referring to a specialist.
In conclusion, to aid in early diagnosis and enable subsequent
early treatment and management, the dental and medical
practitioner (in this case the gynecologist) must have full
knowledge of the diagnostic signs and complications associated
with leukemia.
REFERENCES
1. Williams WJ, Beutler E, Erslev AJ, Litchman MA. Hematology,
4th ed. New York: Mc Graw Hill: 1990. p. 243‑4.
2. Burkett L. Oral Medicine Diagnosis and Treatment. 7 th ed.
Philadelphia: J. B. Lippincott Co; 1977. p. 414‑20.
3. Bressman E, Decter JA, Chasen AI, Sackler RS. Acute myeloblastic
leukemia with oral manifestations. Oral Surg Oral Med Oral
Pathol 1982;54:401‑3.
4. Love A. Manifestations of leukemia encountered in otolaryngologic
and stomatologic practice. Arch Otolaryngol 1963;23:173‑7.
5. Glickman I. Clinical Periodontology, 9th ed. Philadelphia: W.B.
Saunders Co.; 2003. p. 215‑9.
6. Mariotti A. Dental plaque induced gingival diseases. Ann
Periodontol 1999;4:7‑19.
7. Hoffbrand AV, Lewis SM. Post graduate hematology, 4th ed.
London, Oxford university press Inc. 1999: p. 376‑9.
8. Forkner CE. Clinical and pathological differentiation of acute
leukemias with special reference to acute monocytic leukemia.
Arch Intern Med 1934;53:1‑5.
9. Dreizen S, McCredie KB, Keating MJ, Luna MA. Malignant
gingival and skin “infiltrates” in adult leukemia. Oral Surg
1983;55:572‑9.
10. Boggs DR, Wintrobe MM, Cartwright GE. The acute leukemias.
Analysis of 322 cases and review of literature. Medicine
1962;41:163‑225.
11. Shepherd JP. The management of oral complications of leukemia.
Oral Surg 1978;45:543‑8.
12. Osgood EE. Monocytic leukemia: report of 6 cases and review of
127 cases. Arch Intern Med 1937;59:932‑6.
13. Kaufman J. A study of the acute leukoses. Ann Intern Med
1940;14:903‑8.
14. Stafford R, Sonis, S, Lockhart P, Sonis A. Oral pathosis as
diagnostic indicators in leukemia. Oral Surg Oral Med Oral Pathol
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15. Barrett AP. Leukemic cell infiltration of the gingiva. J Periodontol
1986;57:579‑81.
16. Sinrod HS. Leukemia as a dental problem. J Am Dent Assoc
1957;55:809‑18.
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Menezes and Rao: Acute myleomonocytic leukemia with gingival enlargement

17. Barrett AP. Oral changes as initial diagnostic indicator in acute

How to cite this article: Menezes L, Rao JR. Acute myelomonocytic
leukemia. J Oral Med 1986;41:234‑9.
leukemia presenting with gingival enlargement as the only clinical
18. Berkeisev S. Studies on the comparative morphology of monocytic manifestation. J Indian Soc Periodontol 2012;16:597-601.
leukemia, granulocytic leukemia and reticular cell sarcoma.
Source of Support: Nil, Conflict of Interest: None declared.
Cancer 1957;10:606‑16.

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