leukemia is a hematological disorder which is caused by proliferating white blood cell - forming tissues resulting in a marked increase in circulating immature or abnormal white blood cells . leukemia arises from a hematopoitetic stem cell characterized by a disordered differentiation and proliferation of neoplastic cells.1,2 leukemia is characterized into acute or chronic forms , according to its clinical behavior , and characterized as lymphocytic and myelocytic , according to its histogenetic origin . acute myeloblastic leukemia ( aml ) , which is also known as ; acute myelocytic leukemia , acute granulocytic leukemia or acute nonlymphocytic leukemia , is commonly classified under 8 subgroups according to the french - american - british ( fab ) classification system . however in 1997 , the world health organization proposed 4 groups in the aml category.25 patient with aml generally present with symptoms related to complications of pancytopenia ( anemia , neutropenia , and thrombocytopenia ) , including weakness , and easy fatigue , infections of variable severity , and/or hemorrhagic findings such as gingival bleeding , ecchymoses , epistaxis , or menorrhagia . combinations of these symptoms are also common.13 gingival overgrowth is defined as the excessive overgrowth of the gingival tissue . gingival overgrowth has several causes , including poor oral hygiene , medications , serious systemic illnesses , hematological disorders , genetic conditions and it even can be idiopathic.610 oral manifestation in patient with leukemia have been described in all subtypes of aml , chronic myeloid leukemia , acute lymphocytic leukemia , and chronic lymphocytic leukemia.7 gingival infiltration represents a 5% frequency as the initial presenting complication of aml.4,5 gingival infiltration of leukemic cells is most commonly seen in acute monocytic leukemia ( m5 ) and acute myelomonocytic leukemia ( m4).11,12 dreizen et al13 evaluated 1076 leukemic patients and found gingival involvement in 66.7% of m5 patients and 18.5% of m4 patients.8,11,1317 this report defines an aml patient with rapid gingival hyperplasia . the dentist was the first medical examiner who diagnosed the disease , referred her to hematology clinics , and after a successful chemotherapy patient s gingival hyperplasia relapsed together with the remission of the disease . a 17-year - old caucasian woman applied to cumhuriyet university , faculty of dentistry , periodontology clinic with the chief complaint of severe gingival hyperplasia with rapid development in two weeks time . dental examination showed a prominent gingival hyperplasia , in both jaws , especially in the anterior region . the gingival was bulbous , pale and lacked stippling with local erythematic areas ( figure 1 ) . the dentist avoided from using periodontal probe and any periodontal treatment due to the unusual patient history . in the same day , the patient referred to cumhuriyet university , faculty of medicine , hematology clinic with the preliminary diagnosis of leukemia . in medical examination , she suffered from systemic manifestations such as fatigue , nausea , vomit , anorexia , and weight loss in a month . complete blood count , peripheral blood smear and bone marrow biopsy were taken from the patient . complete blood count displayed a decrease in red blood cells with lowered hematocrit and hemoglobin levels ( anemia ) ; and a low platelet count ( thrombocytopenia ) , although white blood cell levels were in normal values , a decrease in neutrophil levels ( neutropenia ) ( table 1 ) . hematology clinic diagnosed the case as aml m5 according to peripheral blood smear and bone marrow biopsy in the several days . after the diagnosis of aml m5 , the patient was only advised brushing her teeth , during the chemotherapy . the patient was given chemotherapy consisting of intravenous administration of cytosine arabinoside ( ara - c , 100 mg / m2/day ( 200 mg ) x 7 days ) and idarubicin hydrochloride ( idamycin , 12 mg / m/ day ( 12 mg ) x 3 days ) . eight weeks following the initial therapy , complete blood count values indicated remission ( table 1 ) . regression of the gingival hyperplasia without performing periodontal therapy was also prominent ( figure 2 ) . one month later following initial therapy , monoblast cells were decreased from 80% to 5% . the patient was taken into maintenance therapy after initial therapy two times for two month . the medical administration was included ; cytosine arabinoside ( ara - c , 100 mg / m/ day ( 200 mg ) x 5 days ) and idarubicin hydrochloride ( idamycin , 12 mg / m2/ day ( 12 mg ) x 3 days ) . although we had recalled the patient after chemotherapy for periodontal therapy , the patient did not come to our clinic . the patient was given chemotherapy consisting of intravenous administration of cytosine arabinoside ( ara - c , 100 mg / m2/day ( 200 mg ) x 7 days ) and idarubicin hydrochloride ( idamycin , 12 mg / m/ day ( 12 mg ) x 3 days ) . eight weeks following the initial therapy , complete blood count values indicated remission ( table 1 ) . regression of the gingival hyperplasia without performing periodontal therapy was also prominent ( figure 2 ) . one month later following initial therapy , monoblast cells were decreased from 80% to 5% . the patient was taken into maintenance therapy after initial therapy two times for two month . the medical administration was included ; cytosine arabinoside ( ara - c , 100 mg / m/ day ( 200 mg ) x 5 days ) and idarubicin hydrochloride ( idamycin , 12 mg / m2/ day ( 12 mg ) x 3 days ) . although we had recalled the patient after chemotherapy for periodontal therapy , the patient did not come to our clinic . even there are several etiologies for gingival overgrowth ; usually each etiology has its own overgrowth characteristics . for example , while genetically induced gingival overgrowth show firm , normal coloured ( pink ) , non - inflamed gingival tissues , gingival overgrowth due to blood dyscrasias are edematous , soft , tender to touch and show tendency to bleed.4,5,9,10,18 gingival hyperplasia is most commonly seen with the aml subtypes acute monocytic leukemia ( m5 ) ( 66.7% ) , acute myelomonocytic leukemia ( m4 ) ( 18.5% ) , and acute myelocytic leukemia ( m1 , m2 ) ( 3.7%).19 in this case report , a rapid gingival hyperplasia together with gingival bleeding was the main reason of the patient to seek therapy . the dentist who examined the patient suspected from the duration of the overgrowth , and from the spontaneous gingival bleeding , without a prominent microbial dental plaque or calculus accumulation . a systemic disease such as probably one of the hematologic diseases was the dentist s early diagnosis , and a hematology consultation was asked . gingival involvement is common in aml and found in 66.7% of the 1076 leukemic m5 patients , in a study by dreizen et al.13 in these kinds of patients , a dental therapy driven without hematological consultation could be fatal . the fact that gingival hyperplasia are sometimes the first manifestation of the disease implies that dental professionals must be sufficiently familiarized with the clinical manifestations of systemic diseases.6,8,11 also a prominent remission was observed in gingival hyperplasia after chemotherapy together with peripheral blood values . this shows that , in cases like aml , elimination of the factor initiating the gingival hyperplasia or maintaining the ideal systemic condition might give a full success in periodontal healing . in this case , our patient s medical condition forced us to do the medical therapy first , because of that the dental therapy of the patients was delayed to see the effect of medical therapy . so , for totally remission of gingival hyperplasia , necessary periodontal therapy must be applied after systemic status was controlled by chemotherapy . as a result , this case reminds that dentists and physicians should be aware of the importance of recognizing oral manifestations of systemic diseases . although physicians most commonly diagnose leukemia , dentists can also diagnose patients with acute myelogenous leukemia . the dental practitioner should have an awareness of diagnostic signs and complications associated with leukemia to better aid in diagnosis and subsequent treatment and management . this case also shows that gingival overgrowth due to acute leukemia is commonly improves by chemotherapy without any periodontal treatment .
acute myeloblastic leukemia ( aml ) is a malignant disease of bone marrow . due to its high morbidity rate , 
 early diagnosis and appropriate medical therapy is essential . rapidly forming gingival hyperplasia 
 is usually the first sign of this disease . 
 this case report describes a 17-year - old female who presented rapid gingival overgrowth together with gingival bleeding in only two weeks time . 
 a medical consultation was asked from hematology clinics and after a detailed medical examination acute monocytic leukemia ( fab m5 ) was rendered . 
 chemotherapy was the choice of treatment . 
 the patient responded well to chemotherapeutic induction regimen and after two months of medical therapy disease remised and gingival hyperplasia regressed . 
 this case report shows that the gingival hyperplasia may represent an initial manifestation of an underlying systemic disease . 
 also , early medical therapy in acute monocytic leukemia may resolve the gingival hyperplasia that companies the disease progression .