Regular oral screening and vigilance: can it be a potential lifesaver?

Acute myeloid leukemia (AML) is a malignant neoplasm of myeloid series defined by the presence of immature blast cells (>30%) in peripheral circulation. Oral manifestations are the potential indicators of systemic health and disease. Oral cavity is the frequently and early involved sites in AML. Gingival overgrowth due to leukemia is one such condition encountered by periodontists. Hence, understanding, identifying, and correlating oral manifestations with systemic diseases are the ultimate responsibility of every dental clinician because of its lethal and unpredictable course. In the present case, we are discussing an undiagnosed case of AML who presented to us with oral complaints.

INTRODUCTION

The health of oral cavity is a remarkable reflection of systemic status.[1] Identification of the signs and symptoms of oral lesions can act as a warning sign of hidden and serious systemic involvement.[1] Gingival overgrowth (GO) is one of the frequently encountered diseases/conditions by the oral health practitioners, especially periodontists.[2] GO can be categorized into inflammatory, drug-induced GO (DIGO), gingival enlargement associated with systemic diseases and conditions, neoplastic, and false enlargement.[3]

Leukemia is a heterogeneous group of hematologic disorders that arise from hematopoietic stem cells, characterized by disordered differentiation and proliferation of neoplastic cells. On the basis of clinical behavior and histogenetic origin, leukemia is classified as acute myeloid leukemia (AML), acute lymphoid leukemia, chronic myeloid leukemia, and chronic lymphoid leukemia. AML is neoplasia of the myeloid series of blood cells, manifested by the rapid growth of abnormal cells with destruction and replacement of bone marrow and presence of anaplastic cells in peripheral circulation. AML progresses rapidly and is typically fatal within weeks or months if left untreated.[4]

The relationship between leukemia and a wide variety of oral lesions has been well documented in many studies.[56] Several undiagnosed cases of leukemia may report to the dentist with chief complaints related to oral lesions.

Oral manifestations of leukemia include petechial hemorrhages (56%), oral ulcerations (53%), gingival enlargement (36%), and spontaneous gingival bleeding.[78] General systemic features include fatigue, anemia, lymphadenopathy, recurrent infections, bone and abdominal pain, enlargement of liver and spleen, bleeding, and purpura.[9] Hereby, we attempt to discuss an undetected case of AML who reported to dental hospital with oral complaints.

CASE REPORT

A 51-year-old male patient reported to the Department of Periodontology, Government College of Dentistry, Indore, with the chief complaint of swollen gums and difficulty in eating. History of present illness revealed that growth was present for 3 months, which gradually increased in size. Medical history revealed recurrent fever associated with weight loss, fatigue, and loss of appetite for the past 3 months. He had been advised analgesics and multivitamins for symptomatic relief at his village. Furthermore, he mentioned abdominal pain and dyspnea on exertion.

On physical examination, the patient was found pale, anemic, hyperthermic, and cachexic. Submandibular lymph nodes were palpable and tender. Systemic examination revealed hepatomegaly and splenomegaly. Spoon-shaped fingernails were observed.

Intraoral examination revealed generalized gingival enlargement involving the buccal, palatal, and lingual region covering almost one-third of anatomic crowns in anterior and two-third in the posterior teeth [Figures 1a–c, 2a and b]. The gingiva was enlarged, ulcerated, painful, and hemorrhagic with fresh bleeding spots signifying spontaneous bleeding. The color of the gingiva ranged from reddish to bluish red indicating cyanotic appearance. Large patches of ecchymosis were also observed over hard palate mucosa [Figure 2a]. Moreover, the patient had fetor oris with poor oral hygiene. The patient had maxillary right posterior missing. No gingival enlargement was seen on edentulous area [Figure 2a].

Figure 1

(a) Labial view; (b) Right lateral view; (c) Left lateral intraoral view showing gingival overgrowth extending one-third of crowns in anteriors and two-third in posteriors, spontaneous bleeding spots at marginal gingiva, gingival ulceration, and cyanotic appearance of gingiva

Figure 2

(a) Maxillary occlusal view; (b) Mandibular occlusal view of gingival growth. No gingival overgrowth seen at edentulous area and ecchymosis seen over hard palate

Radiographic examination revealed no significant osseous changes with slight generalized horizontal bone loss [Figure 3]. Root stumps of 18, 28, and 38 were seen on radiograph. Furthermore, 27 and 38 were proximally carious with periapical radiolucency with respect to 27.

Figure 3

Orthopantomogram revealing no osseous changes with slight to moderate generalized horizontal bone loss

On the basis of severity and extent of GO, gingival ulcerations, gingival bleeding, palatal ecchymosis, and systemic features, a provisional diagnosis of leukemia was made.

The patient was immediately advised complete hemogram which revealed noticeably increased leukocyte count, reduced hemoglobin, and thrombocytes [Table 1]. He was immediately referred to the Department of Oncology, Maharaja Yeshwantrao Hospital, Indore, for further investigation and opinion. The patient was diagnosed as AML (myeloblastic type) on the basis of findings of peripheral blood smear [Figures 4a and b] and bone marrow biopsy. Liver function test, renal function test, screening of hepatitis, and HIV were also conducted [Table 2]. Tests for HIV and hepatitis were negative. The differential white blood cell count and bone marrow biopsy showed 95% blast cells confirming diagnosis of AML [Table 3]. The patient was hospitalized and treatment commenced. However, the patient's condition deteriorated in the next few days, and unfortunately, he succumbed on the 7th day after diagnosis.

Table 1

Hematologic findings of peripheral blood smear

Figure 4

(a and b) Peripheral blood smear of acute myeloid leukemia patient showing numerous blast cells mainly immature leukocytes, erythrocytes, and thrombocytes at (a) ×40; (b) ×100. Black arrow indicates myeloblast cells

Table 2

Liver Function Test & Renal Function Test

Table 3

Bone marrow aspiration report

DISCUSSION

Oral manifestations are observed in 15%–80% of leukemic cases and have been suggested as the potential marker of AML.[10] Differential diagnosis of leukemic gingival enlargement with other gingival enlargement is important because of its lethal and poor clinical outcome. In the present case, there was no positive history of drugs related to DIGO, and there were no other syndromic conditions; therefore, both these entities were ruled out. Positive oral manifestations such as GO, petechiae, ulcerations, and gingival bleeding are attributed to pancytopenia. Pancytopenia may also attribute to severe viral, bacterial, and fungal infections.[11]

Gingival ulcerations and GO may be due to either neutropenia or direct infiltration by the leukemic cells.[12] In the present case, GO was absent in the edentulous region, attributed to the fact that leukemic gingival enlargement is primarily the result of leukemic infiltrate adjacent to bacterial plaque surface.[13] This infiltration leads to increase in gingival thickness and formation of pseudopockets, consequently resulting in secondarily inflammatory component. These oral manifestations and systemic features have led us to the diagnosis of AML.

No specific etiology has been established for AML till date, but various risk factors have been mentioned such as previous chemotherapy/radiation therapy, myelodysplastic syndromes, gene mutation, smoking, exposure to benzene and carcinogenic chemicals, and viral infections (Epstein–Barr virus).

Complete blood count with differential leukocyte count is performed for the preliminary diagnosis of leukemia, which can be further confirmed and graded with bone marrow aspiration and biopsy. Biopsy of gingival tissue can also reveal leukemic infiltrates responsible for altered appearance of gingiva; however, the mere absence of leukemic infiltrates does not rule out the possibility of leukemia.

CONCLUSION

In the present case, the author(s) highlight the need of careful attention on oral manifestations and their correlation with systemic involvement. This may help us in prompt and accurate diagnosis and early management of potentially serious and lethal disease, thereby improving the clinical outcomes.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.