Acute lymphoblastic leukemia (ALL) is one of the most cancers that occur in adolescence and young adult. Despite the recovery of a large number of patients with this type of cancer, there are many complications and oral demonstration remain after healing, which related to leukemia itself or the treatment procedure including chemotherapy and radiotherapy. In general, most of acute lymphoblastic leukemia infected children have poor oral health and may encounter serious oral complication. In this clinical report we present a case of a child that had acute lymphoblastic leukemia and suffering from mucor mycosis in oral cavity, which lead to maxillary necrosis and oronasal connection. The defect in the maxilla, which was very debilitating, was treated by using acrylic obturator, to enhance patient self-confidence and quality of life
Acute lymphoblastic leukemia (ALL) is type of leukemia, or malfunction of the white blood cells, characterized by an increasing production and accumulation of immature white blood cells, known as lymphoblast. The term “acute” means that the leukemia can develop rapidly, and if not treated, would probably be fatal in a short period. Lymphocytic means it develops from immature lymphocytes. There is no specific age for onset of ALL but is more common in children (14 years and less) who represent close to 60% all cases .
Leukemia is generally classified as (1) acute lymphocytic, (2) acute myeloid, (3) chronic lymphocytic, and (4) chronic myeloid. Leukemia classification criteria depend on.
i. The similarity between the leukemic cells and normal cells (myeloid versus lymphoid).
ii. The clinical pathway of the disease (acute versus chronic) .
In a child with ALL, too many stem cells become lymphoblasts, B-lymphocytes, or T-lymphocytes. The cells do not work like normal lymphocytes and cannot fight infection very well . The symptoms of ALL include fever, increased risk of infection (especially bacterial infections such as pneumonia.), increased tendency to bleed (due to thrombocytopenia), and expressive signs of anemia, including pallor, tachycardia (highheart rate), fatigue, and headache . The oral manifestations that may be present are oral infections, ulceration, bleeding, and temporomandibular joint dysfunction mucositis, dysgeusia, xerostomia . Acute leukemia Treatment may include chemotherapy, steroids, radiotherapy, intensive combined treatments (including bone marrow or stem cell transplants), and growth factors . Generally, blood counts fall within a week of treatment and may take some time to recover, depending on the type and doses of drugs used. During this time, there is likely to be a need for antibiotics and other drugs to treat, or prevent infection. There is also likely to be a need for blood transfusions to treat severe anemia, and platelet transfusions to reduce the risk of bleeding . Intensive chemoradiotherapy destroys the mucosal membrane of the mouth and throat and it is often associated with severe oral inflammation and infection, including herpes simplex, candidiasis, mucositis, and gingivitis [8-13]. In addition, these oral complications interfere with patients’ comfort, nutrition and may lead to a systemic infection that arises in the mouth [6,14].
A 13-year-old adolescent suffered from high fever, and after being introduced to a local doctor who described antibiotic and analgesic the temperature got down, but a day later the temperature rose again. This situation has repeated severaltimes. No noticeable improvement was seen, and deterioration
of the general situation of the child to the inability to breathe and
turned the color of the body to yellow, and the appearance of red
spots on the skin. He was transferred to Ali Asghar hospital where
they diagnosed him with leukemia. However, two months after
the first chemotherapy protocol, the patient felt pain in his teeth.
So, he was sent to Alrasool Alkram hospital. Where they found
that he had mucormycosis, he underwent a surgical operation
to debride the infected bone, which was repeated several times
in the following days. This child introduced to Tehran University
of Medical Science (TUMS), school of Dentistry, Department of
prosthodontics, with the chief complaint of oral nasal connection
developed after surgical removal of the defected part of the
maxilla and antibiotic therapy. Clinical examination of a patient
showed loss of the central and lateral incisors canine and first
premolar in the left side, severe bone resorption in the medial
portion of second premolar with mobility class II.
a) Wash the debris in the defect area with normal
saline solution and evaluating the hard palate defect in the
maxillary arch and determining if there is a need for further
surgical or medical intervention the need for prosthetic
intervention (Figure 1).
b) Preliminary impressions of upper and lower arch were
recorded with irreversible hydrocolloid impression material
(Jeltrate; DentsplyIntl, York, Pa) with plastic stock perforated
trays. Impressions were poured with type-III dental stone
and casts were obtained to fabricate the custom tray (Figure
c) Border molding of the custom tray using modeling
plastic impression compound (Impression CompoundType I; Kerr Corp, Orange, Calif) and make the definitive
impression with (CharmFlex Polyvinyl Siloxane (PVS)
Impression Material - Medium Body) (Figure 3).
d) Mounting the cast on an articulator (Hanau 96H2;
Whip Mix Corp, Louisville, Ky) with a maxillomandibular
relation record registered with an aid of the record base and
e) Evaluation the position of the artificial denture teeth
arranged in the wax rim intraorally (Figure 4).
f) Processing the wax denture in heat-polymerized pink
acrylic resin (Lucitone 199; Dentsply Intl) (Figure 5).
g) Inserting the completed obturator intraorally and
evaluating the fitting using pressure-indicating paste
(Mizzy, Inc; Cherry Hill, NJ), and equilibrate the occlusion.
Evaluate the speech and swallowing functions and esthetics
to ensure patient comfort (Figure 6). It was important to
take into account the fact that this child was in the growthphase and constantly adjust the device to commensurate
with the continued growth of the maxilla. Recall for the
patient is usually done every 2 weeks due to rapid soft-tissue
changes that occur within the defect during organization
and healing of the wound. Follow up the patient after three
years, a complete improvement in the patient’s condition
was achieved and the Patient relieved completely from his
illness. Our patient came to make some adjustment for his
prostheses. He lost his left second premolar. We just added
new tooth to his obturator and confirmed on oral hygiene
care (Figure 7).
Leukemia is a malignancy affecting the white blood cells
of the bone marrow . Palate perforation can occur due to
trauma, bacterial infection such as osteomyelitis, Wegener’s
granulomatosis, viral infection such as herpes zoster, fungal
infection such as mucormycosis, aspergillosis, prolonged
cocaine abuse, and malignancies . Prosthetic rehabilitation
of the palatal perforation with obturator by a maxillofacial
prosthodontist has two primary objectives :
i. To optimally restore the functions of mastication,
deglutition, and speech thereby improving and enhancing
the quality of life of these patients.
The increased risk for systemic fungal infection and the
potential fatal consequences spread in patients receiving
bone marrow transplants or antineoplastic therapy. And this
have indicated the importance of prevention of, mucositis,
ulceration, hemorrhage or infection because the condition can
be exacerbated and lead to changes Irreversible bone necrosis
that progressed in our patient and led to contact between the
oral and nasal cavities. The oral health status of hospitalized
children suffering from leukemia or other cancers is generally
poor. They should be considered, as high-risk patients for oral
complications and this situation require a special care and
recurrent follow up session under supervision of well-trained
dentists and medical teams.