Orthodontic treatment for a patient with acute myeloid leukemia.

Acute myeloid leukemia (AML) is the most common type of blood cancer in adults. Chemotherapy, hematopoietic stem cell transplantation, and immunosuppressive drugs, such as cyclosporine A, are common treatment modalities for AML. Due to the nature of the disease and accompanying treatments, complications such as cytopenia, infection, gingival hyperplasia, oral ulcerations, and change of bone metabolism are often causes for concern when considering dental treatment.1, 2, 3, 4 When a patient requiring orthodontic treatment is diagnosed as having AML, the postponement of orthodontic treatment and removal of orthodontic appliances is always suggested. In this report, we presented a female patient who developed AML and received further immunosuppressant therapy when undergoing orthodontic treatment. The orthodontic treatment was well tolerated by the patient and yielded satisfactory results.

This 25-year-old woman presented in our hospital with a chief complaint of some spaces around her mandibular teeth. Clinical examination revealed a well-proportioned straight facial profile, angle class I malocclusion, an overjet of 3 mm, an overbite of 4 mm, a mild crowding of the upper dentition, and two congenital missing teeth of 31 and 41. The treatment plan included distalization of her upper arch by using temporary anchorage devices and closure of the spacing through protraction of the lower posterior teeth.

The woman's orthodontic treatment began in April 2008. In October 2008, she was hospitalized after receiving a diagnosis of AML. Due to poor response to standard chemotherapy, peripheral stem cell transplantation was performed in March 2009, and the long-term immunosuppression with cyclosporine A became essential. The woman did not return to our clinic, and she asked to continue orthodontic treatment until July 2009. Clinicians explained the risks to the patient before she decided to commence a noninvasive treatment plan involving the use of bite turbos and light interarch elastics to replace the use of temporary anchorage devices and minimize any possible complications. In addition, the instruments were carefully manipulated to avoid iatrogenic trauma. Her orthodontic treatment was completed in July 2010. Both the dental alignment and facial profile were improved after orthodontic treatment (Fig. 1).

Figure 1

Clinical data for our patient with orthodontic treatment and concurrent immunosuppressant therapy. (A) Pretreatment extra-oral photographs. (B) Posttreatment extra-oral photographs. (C) Pretreatment intraoral photographs. (D) Progressive intraoral photographs, depicting the teeth after application of bite turbo and light interarch elastics for overjet reduction and space closure. (E) Posttreatment intraoral photographs. (F) Comparison of pretreatment and posttreatment cephalometric films.

Orthodontic treatment in a patient receiving immunosuppressants is highly complicated and contentious because cyclosporine A may cause gingival overgrowth that makes tooth cleaning difficult, and because cyclosporine A can change the bone metabolism and result in suppression of host defense. Therefore, the removal of all appliances or postponement of orthodontic treatment is suggested. Fortunately, periodontal disease did not occur in this patient, because the patient maintained good oral hygiene. Lukus et al. suggested that the risk of bacteremia does not significantly increase after archwire adjustment. Therefore, we kept close contact with the patient's physician to monitor her health condition. This enabled us to continue her orthodontic treatment in a nonintrusive manner. In our opinion, the decision of whether to delay or cease orthodontic treatment mainly depends on the patient's health condition and the complexity of treatment. Appropriate orthodontic treatment protocol and devices along with good patient compliance help achieve satisfactory results in such difficult situations. Further investigation is required to determine how cyclosporine A influences tooth movement in humans.

Declaration of competing interest

All the authors declare no potential financial and nonfinancial conflicts of interest.