Colleagues,

As periodontists, we occasionally encounter patients whose oral presentations suggest underlying systemic disease.
This newsletter highlights manifestations of leukemia that can be easily screened for in a dental setting, and shares a recent case that underscores the importance of vigilance.

Case Presentation: AML in a Periodontitis Patient

A male patient in his 40s with no significant medical history and a recent clean bill of health from his PCP presented for evaluation.
He had achieved periodontal stability following LANAP treatment 4 years prior. After a recent cleaning with his general dentist, he developed progressive inflammation.

Initial Findings: Increased probing depths, bleeding, and bone loss compared to previous exams. The patient also exhibited increased halitosis compared to previous maintenance visits. The patient’s clinical findings indicated a periodontitis flare-up and periodontal abscesses from incomplete calculus removal during a recent dental cleaning.

Same Day Treatment Provided: LANAP retreatment and extraction of maxillary third molars.

Post-operative Course

Over the following two weeks, the patient developed:

• Multiple liver clots at surgical sites
• Progressive edema and erythema of gingiva and extraction sites
• At one week: Ecchymosis and ulcerations were present intra and extraorally

CT showed sinus opacity and cortical break in right maxillary sinus—a finding concerning for aggressive bone destruction that can indicate leukemic infiltration or pathologic bone resorption; ENT referral made.

Increased halitosis leading to suspicion of anaerobic bacterial involvement. Augmentin and metronidazole were prescribed.

At two weeks: Halitosis was no longer present following antibiotics, but delayed wound healing persisted, and further increased erythema and edema were present throughout treated areas. Patient had been unable to see ENT up to this point.

Outcome: Patient was sent to the emergency department for immediate evaluation, where he was diagnosed with acute myeloid leukemia.

Oral Manifestations of Leukemia

Oral signs occur in approximately 30% of patients with newly diagnosed acute leukemia, though classic findings like gingival enlargement are present in only about 6% of cases.[1][2] Key oral manifestations include:

• Gingival enlargement or hyperplasia (particularly in acute myeloid leukemia with monocytic subtypes)[3][2]
• Spontaneous gingival bleeding and mucosal bleeding[4][2]
• Petechiae and ecchymoses of the oral mucosa[4][2][5]
• Oral ulcerations and mucosal pallor[4][2][5]
• Poor wound healing following dental procedures[5]
• Unexplained periodontal deterioration despite previous stability[6]
• Infections (candidiasis, recurrent herpes)[2][5]
• Halitosis from oral infections, necrotic tissue, or poor oral hygiene[7][8]

Radiographic Bone Findings

Leukemia can cause significant bone changes in the maxillofacial region that may be visible on dental imaging:

• Osteolytic lesions with ill-defined borders and bone destruction are the most common radiographic findings[9][10]
• Cortical bone erosion or destruction, including breaks in the cortical plate, may indicate leukemic infiltration or aggressive bone resorption[9][10][11]
• Diffuse osteopenia and loss of trabecular pattern[12][13]
• Periosteal reactions are uncommon in leukemia, which can help differentiate from infectious processes[10]

Cortical bone destruction in leukemia results from multiple mechanisms: direct leukemic cell infiltration, increased osteoclast activity mediated by cytokines (particularly TNFα and RANKL), and impaired osteoblast function.[14][15][16] When cortical breaks are identified in patients with suspected malignancy, they may represent aggressive disease requiring urgent evaluation.[9][11]

Skin Manifestations

Leukemia cutis—infiltration of leukemic cells into the skin—occurs most commonly with acute myeloid leukemia and chronic lymphocytic leukemia.[17] Presentations include:

• Papules, nodules, plaques, or purpuric lesions[17][18]
• Typically purpuric nodules in acute myeloid leukemia[3]
• Ecchymoses and petechiae from thrombocytopenia[19]
• Lesions most frequently appear on the trunk and extremities[17]

Key Takeaways

When you encounter patients with unusual gingival presentations, spontaneous bleeding, atypical responses to periodontal therapy, or concerning radiographic bone changes, consider leukemia in your differential diagnosis. We encourage you to refer patients with concerning findings for comprehensive evaluation.

Thank you for your continued partnership in patient care.

Best,
Matthew Flaherty, DDS

References