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Leukemic infiltrates refer to the accumulation of malignant leukemic cells within tissues outside the bone marrow. In the oral and maxillofacial region, leukemic infiltrates are of particular importance because oral signs may be among the earliest indicators of undiagnosed leukemia. Dental professionals are often the first healthcare providers to encounter these manifestations.
Definition and Pathogenesis
Leukemic infiltrates occur when neoplastic leukocytes migrate from the bloodstream into extramedullary tissues, including the oral mucosa, gingiva, and jaw bones. These infiltrates disrupt normal tissue architecture and are frequently associated with systemic hematologic abnormalities.
They are most commonly seen in:
- Acute leukemias, especially acute myeloid leukemia (AML)Epidemiology
- More frequent in acute leukemia than chronic leukemia- Occur in both children and adults
- Gingival involvement is particularly common in monocytic leukemias
- Oral manifestations may precede systemic diagnosis
Common Oral and Maxillofacial Sites
- Gingiva (most common site)- Palate
- Tongue
- Buccal mucosa
- Jaw bones (rare)
Gingival tissues are especially susceptible due to rich vascularity and chronic inflammatory stimuli.
Clinical Presentation
Gingival Manifestations
- Diffuse or localized gingival enlargement- Boggy, soft, friable consistency
- Reddish-purple discoloration
- Bleeding with minimal trauma
- Poor response to conventional periodontal therapy
Other Oral Findings
- Non-healing ulcers- Mucosal pallor (anemia)
- Petechiae and ecchymoses (thrombocytopenia)
- Spontaneous gingival bleeding
- Opportunistic infections (e.g., candidiasis, herpes simplex)
Jaw involvement may present as:
- Tooth mobility- Bone pain
- Ill-defined radiolucencies on radiographs
Pathology
Histopathological Features
- Dense infiltration of atypical leukemic cells within connective tissue- Effacement of normal tissue architecture
- Cells resemble immature leukocytes (blasts)
- Minimal inflammatory response
Immunohistochemistry
Helps identify leukemic lineage:
- Myeloperoxidase (MPO) for myeloid leukemias
- CD33, CD34 for AML
- CD3, CD7 for T-cell lineage
- CD19, CD20 for B-cell lineageDifferential Diagnosis
Leukemic infiltrates may clinically mimic:
- Drug-induced gingival enlargement (phenytoin, cyclosporine, calcium channel blockers)- Inflammatory gingival hyperplasia
- Periodontal disease
- Lymphoma
- Kaposi sarcoma
Failure to respond to routine periodontal treatment is a key warning sign.
Diagnostic Approach
Dental professionals should suspect leukemic infiltrates when encountering:
- Sudden onset gingival enlargement- Excessive bleeding disproportionate to local factors
- Systemic symptoms (fatigue, fever, weight loss)
Recommended Actions
- Obtain a thorough medical history- Order or recommend complete blood count (CBC)
- Refer urgently to a physician or hematologist
- Biopsy may be performed cautiously due to bleeding risk
Imaging Characteristics
- Jaw radiographs may show:= Diffuse or patchy radiolucencies
Management Principles
Medical Management
- Treatment is directed at the underlying leukemia- Chemotherapy is primary therapy
- Gingival enlargement often regresses with systemic treatment
Dental Management
- Avoid invasive procedures until hematologic status is stabilized- Manage oral infections aggressively
- Emphasize meticulous oral hygiene
- Coordinate care with oncology team
Prognostic Significance
- Presence of leukemic infiltrates often indicates:= Advanced disease
Importance for Dental Professionals
Dental practitioners play a critical diagnostic role:
- Early detection of oral signs may lead to life-saving diagnosis- Avoid misdiagnosis as simple periodontal disease
- Prompt referral can significantly affect prognosis
- Long-term oral care is essential during and after cancer therapy
Conclusion
Leukemic infiltrates are a vital example of how systemic malignancies manifest in the oral cavity. Awareness of their clinical presentation enables dental professionals to identify leukemia at an early stage, initiate appropriate referrals, and contribute meaningfully to patient survival and quality of life.