Gingival Enlargement in Acute Monoblastic and Monocytic Leukemia

Keith E. Lewis, MD
Tracey Samko, MD
Erika Escobedo, MD
Daniel Im, MD
Jenny L. Wong, cPed, Cfts, CCWS, DMD, MD
Cynthia H. Ho, MD
Randall Y. Chan, MD
Volume 56 - Issue 6 - June 2016

An 18-year-old boy presented with fever, weight loss, gingival enlargement, and pain for 2 weeks. On physical examination, he had generalized pallor and diffuse adenopathy. The gingival enlargement was causing muffled speech and impairing mastication.

His white blood cell count was 115,300/μL with 85% blasts, hemoglobin was 10.7 g/dL, and platelet count was 42x103/μL.

Diagnostic testing. Morphologic analysis of the peripheral blood confirmed by immunohistochemistry and flow cytometry revealed World Health Organization-classified acute monoblastic and monocytic leukemia, formerly classified as French-American-British (FAB) M5 acute myeloid leukemia (AML).

Discussion. The most common cause of gingival enlargement is inflammation from hardened plaque (dental calculus).1 The terms enlargement or overgrowth are preferred over hypertrophy or hyperplasia, since the latter 2 terms are histopathologic descriptors.1 The second most common cause is drug-induced overgrowth, which develops over 1 to 3 months,2 from anticonvulsants, calcium-channel blockers, and immunosuppressants.3 Rarely, gingival enlargement is idiopathic or inherited in an autosomal dominant fashion.4

Rapid gingival enlargement should raise concern for gingival chloroma, an extramedullary collection of leukemic cells.5 Gingival chloromas classically are associated with myelomonoblastic as well as monoblastic and monocytic AML (FAB M4 and M5).6,7 Notably, extramedullary manifestations of AML, including gingival chloroma and leukemia cutis, portend a poor prognosis8 and may present prior to bone marrow involvement.9 Leukemic cells may also infiltrate periapical tissues of the teeth and present with tooth pain and extrusion.10,11

In addition to cosmetic concern, gingival enlargement can impair speech and mastication.1 Inflammation from bacterial entrapment by plaque occurs due to difficulty with brushing of the teeth and leads to infection and bleeding.1 In patients with AML, gingival changes completely resolve with successful treatment of leukemia. In contrast, drug-induced gingival overgrowth improves within 6 months of drug cessation; however, long-term changes may persist due to gingival fibrosis.12 Regardless of the etiology, good oral hygiene, chlorhexidine mouthwashes, and plaque control are important adjunctive therapies.

References:

  1. Carranza FA, Hogan EL. Gingival enlargement. In: Newman MG, Takei HH, Klokkevold PR, Carranza FA, eds. Carranza’s Clinical Periodontology. 12th ed. St Louis, MO: Elsevier Saunders; 2015:chap 16.
  2. Meraw SJ, Sheridan PJ. Medically induced gingival hyperplasia. Mayo Clin Proc. 1998;73(12):1196-1199.
  3. Dongari-Bagtzoglou A; Research, Science and Therapy Committee, American Academy of Periodontology. Drug-associated gingival enlargement. J Periodontol. 2004;75(10):1424-1431.
  4. Doufexi A, Mina M, Ioannidou E. Gingival overgrowth in children: epidemiology, pathogenesis, and complications: a literature review. J Periodontol. 2005;76(1):3-10.
  5. Byrd JC, Edenfield WJ, Shields DJ, Dawson NA. Extramedullary myeloid cell tumors in acute nonlymphocytic leukemia: a clinical review. J Clin Oncol. 1995;13(7):1800-1816.
  6. Koudstaal MJ, van der Wal KGH, Lam KH, Meeuwis CA, Speleman L, Levin MD. Granulocytic sarcoma (chloroma) of the oral cavity: Report of a case and literature review. Oral Oncol Extra. 2006;42(2):70-77.
  7. Bakst RL, Tallman MS, Douer D, Yahalom J. How I treat extramedullary acute myeloid leukemia. Blood. 2011;118(14):3785-3793.
  8. Paydas S, Zorludemir S, Ergin M. Granulocytic sarcoma: 32 cases and review of the literature. Leuk Lymphoma. 2006;47(12):2527-2541.
  9. Krause JR. Granulocytic sarcoma preceding acute leukemia: a report of six cases. Cancer. 1979;44(3):1017-1021.
  10. Neville BW, Damm DD, Allen CM, Bouquot JE. Pulpal and periapical disease. In: Neville BW, Damm DD, Allen CM, Bouquot JE, eds. Oral and Maxillofacial Pathology. 3rd ed. St Louis, MO: Saunders Elsevier; 2009:120-153.
  11. Neville BW, Damm DD, Allen CM, Bouquot JE. Hematologic disorders. In: Neville BW, Damm DD, Allen CM, Bouquot JE, eds. Oral and Maxillofacial Pathology. 3rd ed. St Louis, MO: Saunders Elsevier; 2009:571-612.
  12. Camargo PM, Melnick PR, Pirih FQM, Lagos R, Takei HH. Treatment of druginduced gingival enlargement: aesthetic and functional considerations. Periodontol 2000. 2001;27(1):131-138.