Journal of Indian Society of Periodontology
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Year : 2021  |  Volume : 25  |  Issue : 4  |  Page : 347-349  

Oral manifestations of systemic leukemia-first sign of presentation

1 Department of Oral Medicine and Radiology, People's College of Dental Sciences and Research Centre, Bhopal, Madhya Pradesh, India
2 Department of Oral Medicine and Radiology, Rajendra Institute of Medical Sciences, Medical Institute of Ranchi University, Ranchi, Jharkhand, India
3 Department of Oral Medicine and Radiology, Bhabha Dental College, Bhopal, Madhya Pradesh, India

Date of Submission26-Jul-2020
Date of Decision26-Jan-2021
Date of Acceptance09-Feb-2021
Date of Web Publication01-Jul-2021

Correspondence Address:
Annette Milton Bhambal
Department of Oral Medicine and Radiology, College of Peoplefs Dental Sciences and Research Centre, Bhopal, Madhya Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisp.jisp_551_20

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Acute myeloid leukemia (AML) is an aggressive hematopoietic malignancy that left untreated or undiagnosed can lead to death within few days. Hence, early diagnosis and appropriate treatment become necessary. Oral manifestations in AML could be the presenting feature or could a part of systemic manifestations. Gingival lesions appear as generalized enlargement with hemorrhagic discoloration with or without spontaneous bleeding. Sometimes, gingival lesions itself could a presenting sign without any other systemic manifesto. We report a similar case which was undiagnosed earlier and the patient came with a complaint of only the gingival swelling.

Keywords: Acute myeloid leukemia, bleeding, chloroma, gingival overgrowth, hematologic neoplasm, oral manifestations

How to cite this article:
Bhambal AM, Shrivastava H, Naik SP, Nair P, Saawarn N. Oral manifestations of systemic leukemia-first sign of presentation. J Indian Soc Periodontol 2021;25:347-9

How to cite this URL:
Bhambal AM, Shrivastava H, Naik SP, Nair P, Saawarn N. Oral manifestations of systemic leukemia-first sign of presentation. J Indian Soc Periodontol [serial online] 2021 [cited 2021 Sep 19];25:347-9. Available from:

   Introduction Top

Leukemia is a hematologic neoplasm characterized by abnormal proliferation and differentiation of hematopoietic stem cells. This results in pancytopenia and severe malfunctioning of organ systems. Death in these cases occurs secondary to infection and bleeding or both. It is a multifactorial disease, although certain carcinogenic factors have been listed.[1]

According to Francisconi et al., leukemias are classified into acute and chronic lesions which are further subdivided into myeloid and lymphoid variants. Oral lesions can appear in acute and chronic cases, although acute cases have more of oral manifestations.[2]

Erythematous or cyanotic gingival enlargement is most commonly seen. Enlargement occurs secondary to leukemic infiltrates.[3] Enlargements in leukemic cases are of sudden onset and hardly associated with any local factors. In these cases, suspicion of leukemic enlargement could be thought of. Although other sign and symptoms could be present such as fever, weight loss, herpetic infections secondary to immunodeficiency, tiredness, petechiae, and ecchymosis.[4]

We present a case of acute gingival enlargement which was probably the last stage of illness which went unnoticed and eventually patient succumbed to death. This highlights the importance of patient awareness itself since our patient did not realize the severity of the disease and we lost the patient in a span of few days after we diagnosed him as acute myeloid leukemia (AML).

   Case Report Top

A 50-year-old male patient came to us with a complaint of swollen gums since 15 days. He was a farmer by occupation. Patient gave a history of tooth removal (as they were mobile) 20 days back, 4–5 days after which gum swelling appeared that gradually increased. The patient also gave a history of reduction in size of the gum swelling since the last 4 days. The patient did not complain of any gum bleeding except for slight pain in gums while eating. No significant history of hypertension, hyperglycemia, hyper or hypothyroidism, weight loss or any kind of bleeding disorders was elicited from the patient. The patient had a habit of chewing pan supari for 8–10 years, 4–5 times a day and had quit the habit since the last 3 years. He was treated with ofloxacin, nimesulide, and omeprazole for the same. General physical examination revealed pallor on the fingers and palms, but no lymphadenopathy was elicited.

Intraorally, generalized gingival enlargement was noted involving buccal/labial, lingual/palatal gingiva, involving the attached and marginal gingiva as shown in [Figure 1] and [Figure 2]. It extended from mucogingival junction to occlusal 3rd or incisal 3rd of teeth. At few areas, the gingival is extending onto crown only to spare the occlusal and incisal aspect of teeth. Color appeared pale pink to red to purple. Areas of melanin pigmentation were also seen at the mucogingival junction. Gingival appeared boggy but firm in consistency. Fresh spontaneous bleeding was also evident. On palpation bleeding was elicited, nontender. Pseudopockets were present. The extraction site in relation to 46 was filled with gingival and root stumps seen in relation to 36. No other significant intraoral findings were noted. No ecchymosis was evident elsewhere on any other part of oral mucosa.
Figure 1: Intraoral photograph showing gingiva of upper and lower anterior segment

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Figure 2: Intraoral photograph showing gingiva of the mandible

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Based on the clinical findings and history provisional, diagnosis of malignant gingival enlargement was thought. Inflammatory was ruled out since no local factors were present. Drug-induced was ruled since the patient was not taking any kind of medications. Later complete blood picture was advised. Complete blood picture showed raised lymphocytic count and peripheral smear showed myeloblasts as observed in [Figure 3]. Based on the blood picture final diagnosis of AML was made and the patient referred to oncology center. Unfortunately, we lost the patient in span of few days after we diagnosed him as a case of AML and before a definitive treatment plan could be initiated. Patient consent was obtained prior to investigations and clinical photograph.
Figure 3: Photomicrograph of peripheral smear showing myeloblasts

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   Discussion Top

Leukemia a malignancy of white blood cells is classified as lymphoid or myeloid and acute and chronic disease. Its runs a chronic course and could go undiagnosed for months to years. Acute leukemia has an abrupt onset and uninterrupted proliferation of poorly differentiated blast cells. Undiagnosed cases are aggressive and prove to be fatal.[5]

Triggering factors include ionizing radiation, cytotoxic therapy, viral infections, and surgical procedures like extraction.[6] Oral lesions are seen more frequently with acute leukemia and could be a result of direct infiltration of leukemic cells into gingival tissues or secondary to neutropenia, impaired granulocyte function, or thrombocytopenia.[6]

Oral manifestations of leukemia include generalized gingival enlargement which is hemorrhagic, blue to purple to red covering the tooth surface either partially or completely thus making tooth visibility obscure. Chloromas or granulocytic sarcomas are specific lesions of AML which rarely occur in the oral cavity. It is an extramedullary tumor mass which is localized and composed of immature myelocytes. They can occur in the gingiva, lymph nodes, and soft tissues and is capable of local tissue destruction and invasion.[1] Tooth indentations could occur on the enlargements. Gingiva appears spongy with increased tendency to bleed. Leukemic gingival enlargement is not seen in edentulous patients suggesting the role of local factors in preceding the enlargements.[7]

Other manifestations include oral ulcers, vesiculobullous lesions, pale mucosa, cracked lips, herpes and candidiasis. There are other general physical findings such as fever, pain in bones, and history of weight loss and others.

The diagnosis could be done clinically too if the patient presents with all classical findings of leukemia. Simple yet the conclusive evidence for leukemia comes from a complete blood hemogram. It shows raised lymphocytic count and reduced RBCs and hemoglobin%. A peripheral blood picture could establish the final diagnosis by showing the type of cell lineage like in this patient. However, the final diagnosis comes after a bone marrow aspirate examination.

The treatment should be aggressive for these cases or we might lose patient. It includes aggressive multidrug therapy along with allogenic bone marrow transplantation. Once the patient starts with chemotherapy, oral manifestations might regress on their own. However, palliative oral therapy should be instituted to patient for oral discomfort. Periodontal and dental treatment should be inferred after physician's consent and under prophylactic measures. Chlorhexidine and benzydamine hydrochloride rinses should be advised as part of palliative therapy. Chemotherapy might be associated with mucositis, this can be managed by palliative oral care along with pain control achieved by nonopioids.

In the present case, although we referred the patient for chemotherapy to a higher center, before any treatment could be instituted patient on his own went to another dentist who performed an oral prophylaxis in him. This might have triggered the blood loss, and eventually patient succumbed to death within 2 days. This emphasizes on patient education post the diagnosis.

Our case is different from the other cases because usually diagnosed leukemic cases are referred from general medicine for the management of their oral conditions. However, in this case, it was the oral physician who, after examining the clinical features, gave the diagnosis that our patient was suffering from leukemia. He was then referred to the cancer hospital for treatment. However, he escaped from there and got an oral prophylaxis elsewhere thinking that it was due to stains and calculus which unfortunately turned out to be fatal.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Arora PC, Arora A, Arora S. Oral manifestations as an early clinical sign of acute myeloid leukemia: A report of two cases. Indian J Dermatol 2020;65:241-3.  Back to cited text no. 1
  [Full text]  
Francisconi CF, Caldas RJ, Oliveira Martins LJ, Fischer Rubira CM, da Silva Santos PS. Leukemic oral manifestations and their management. Asian Pac J Cancer Prev 2016;17:911-5.  Back to cited text no. 2
Rosa BPP, Ito FA, Trigo FC, Mizuno LT, Junior AT. Oral manifestation as the main sign of an advanced stage acute promyelocytic leukemia. Acta Stomatol Croat 2018;52:358-62.  Back to cited text no. 3
Menezes L, Rao JR. Acute myelomonocytic leukemia presenting with gingival enlargement as the only clinical manifestation. J Indian Soc Periodontol 2012;16:597-601.  Back to cited text no. 4
[PUBMED]  [Full text]  
Dean AK, Ferguson JW, Marvan ES. Acute leukaemia presenting as oral ulceration to a dental emergency service. Aust Dent J 2003;48:195-7.  Back to cited text no. 5
Benson RE, Rodd HD, North S, Loescher AR, Farthing PM, Payne M. Leukaemic infiltration of the mandible in a young girl. Int J Paediatr Dent 2007;17:145-50.  Back to cited text no. 6
Cooper CL, Loewen R, Shore T. Gingival hyperplasia complicating acute myelomonocytic leukemia. J Can Dent Assoc 2000;66:78-9.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3]


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