Year : 2008 | Volume
: 20 | Issue : 2 | Page : 74--76
Acute myeloid leukemia with oral manifestations: Case report and brief overview
Kruthika S Guttal1, Venkatesh G Naikmasur1, Krishna N Burde1, Akhil C Deka2,
1 Department of Oral Medicine and Radiology, SDM College of Dental Sciences, Sattur, Dharwad-580 009, Karnataka, India
2 Karnataka Cancer Hospital and Research Centre, Navnagar Hubli, Karnataka, India
Kruthika S Guttal
Department of Oral Medicine and Radiology, SDM College of Dental Sciences and Hospital, Dharwad 580 009, Karnataka
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.
|How to cite this article:|
Guttal KS, Naikmasur VG, Burde KN, Deka AC. Acute myeloid leukemia with oral manifestations: Case report and brief overview.J Indian Acad Oral Med Radiol 2008;20:74-76
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Guttal KS, Naikmasur VG, Burde KN, Deka AC. Acute myeloid leukemia with oral manifestations: Case report and brief overview. J Indian Acad Oral Med Radiol [serial online] 2008 [cited 2023 Feb 8 ];20:74-76
Available from: http://www.jiaomr.in/text.asp?2008/20/2/74/44370
Leukemias are considered to be potentially lethal diseases in which there is neoplastic proliferation of bone marrow white blood cells.  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.  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.
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.
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.
As a part of further investigations, heamatological tests were advised. Reports revealed the red blood cells counts to be 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.
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.
AML results from abnormal proliferation and differentiation of hemopoietic progenitor cells.  The cells fail to differentiate and then proliferate uncontrollably. The immature myeloid or blast cells accumulate and replace bone marrow,  implying manifestations to be marrow failure and cytopenia. 
The incidence of AML increases with age, with peak in the 6 th decade.  It is believed that less than half of the cases occur in patients younger than 50 years. 
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). 
Gingival swelling is seen in 20-30% of patients with AML  this results from an abnormal response to dental plaque 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.  Gingiva appear swollen, devoid of stippling and pale red to deep purple in color.  Also observed are mucosal hemorrhages, ulcerative gingivitis, infectious gingivitis and odontalgia.  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. 
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]. 
Traditional therapy for AML includes remission induction and post remission therapy.  The goal of remission induction is to reduce the number of leukemic cells below clinical detection allowing normal hematopoiesis  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.  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 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. 
Post remission treatment options include short-term intensive consolidation chemotherapy or high dose myeloablative chemotherapy with or without radiotherapy combined with bone marrow transplant. 
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.  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.  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.
The authors would like to acknowledge Dr. C. Bharsker Rao, Principal, SDM Dental College Dharwad.
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