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Chronic lymphatic leucemia
CHRONIC
LYMPHATIC REPORT
IV.
N.
BURFORD,
OF
LEUCERIIA A
D.D.S.,
CASE COLKVIBIA,
110.
A
FACT that is being constantly overlooked by all of us is the relation of We, as dentists, have long been chided for the mouth to the entire body. our failure to see beyond the cavities in the teeth and the edentulous areas. Regretfully, we have to admit to such criticism because of our purely mechanical Personally, I think the restorative side of dentistry interest in the oral cavity. has reached a point of saturation and we would do well to let it rest upon its laurels for a time. Our future interests and advancements should be concerned with the health of the soft tissues of the mouth and the relation of these tissues to the health of the entire body. A great, many systemic disorders manifest themselves within the oral cavity at one time during their clinical course. This manifestation may be as evident Most diseases of this as the mucous patches of syphilis, or it may be obscure. type are insidious and, therefore, difficult to recognize at a time when recognition is most important. But, we should feel it our dut,y to become so well informed that very little within the mouth will be missed. It is not my purpose to list all systcrnic diseases we may expect to see manifested in the mouth. I wish to present only one case, and I will cndeavor to prove how important early recognition upon the part of the dentist can be. Leuccmia is an invariably fatal systemic disease of unknown etiology, priAt first marily involving the blood-forming organs, among them the spleen. glance, I can think of nothing more removed from our field than the human spleen. However, its action will place us squarely in the clinical picture of all types of leucemia. One of the most important clinical signs of any type of lencemia is the diffuse, marked swelling of the mucous membra.nes of the mouth and upper respiratory tract. This swelling is associated with a tendency of these membranes to hemorrhage. Gingivae will bleed at such insignificant trauma as toothbrushing. Hypertrophy of the gums. especially at the interdental spaces, plus the bleeding I have mentioned, presents a picture closely simulating simple gingivitis. I have seen some cases, and the case I am presenting is one of them, diagnosed as p>-orrhea. I am certain a more thorough examination of the patients, on our part, will make for less careless diagnoses. The diffuse marked swelling of the mucous membranes, and the increased tendency to bleed, is sometimes the initial symptom which causes patients to Because of the nature of this complaint, a large major*seek professional advice. it>- of such pat,ients first consult their dentist. The latter must exercise every caution because it frequently happens that he does not realize the seriousness of Oral
Surgeon
to
Ellis
Fischel
State
Cancer 549
Hospital.
Columbia,
Mo.
lhc situation, and may make one or more extractions, which may be followed by uncontrollable hemorrhage, ulcer&ion, and in some cases, osteomyelitis. Farreul and Landais (1931), Pollosson and Lebeuf (1933), and others have reported the occurrence of noma, or gangrenous stomatitis, following the ext,raction of a tooth in patient,s with leucemia. Forkner (1934) showed that in each of six eases of acute monocytic leuccmia the patients’ first complaints were swelling of the gingivae with subsequent ulceration and necrosis. Each of these paCents first consulted dentists before finally consulting their physician. Chronic lymphatic leuccmia represents the largest group numerically of all leucemias. This includes the typical rasc usuallspoken of as lymphatic leucemia with l~rn~~,haclerloI)atfl~ and moderate splenomegalp, moderate anemia and marked elevation of the total white blood cell count, consisting almost entirely of Iymphocytcs. REPORT J.
II.,
on March was
a white
sliglltly
on
physicians
of
age{1 chief thp
being
ant1
40
left
dental
Tntroor:rl spaces.
with
crown
of
the
lower
left
Bornt
of
cddus
Mrdicnl
no first
was
startetl able to to
use
molar
tlestrojwl,
right first the apes. present
extractions finish only
on March the lower
An
left
himself
sitlr
of
the
in~purtant
my
at
o&e by enlargement
on
his of
the
of
physician the left
He stated an11 perfectly
he all
the
of roots
the teeth
Thr
llatient
at
the
gums were
gainer1
been to at He com-
of the left right. The patient’s
especially clecayetl,
resorption first
subma,99
general
at tlirty,
the interwith the
of
the
alveolus
molar roots presented tooth, with a well-tlefinecl,
were lower
seen on anterior
to his
physician
for
that within
the Kahn normal
all fillings, teeth. a Kahn
was
evidence rather ant1
test,
an
tlifferen-
reaction and urinalysis limits and the cdlotting
lynlphatlenitis. all
teeth
with the
careful poor
curettage rooperaticm
of
the
of
the
time
weight
sockets. patient,
copious ljleetling, am1 twicse it ~2s to arws;t the hemorrhage. I never
was
the
Ry c*lewnwl of its pathology. the right and left sul~maxillx~~p steallily
for treatment submaxillary
had right.
The
margins of the
16, 1929, ant1 tine to jaw by Oct. 20, lR3.
me
office tongue
remaining.
horizontal
patient
swelling on the
manipulation.
The
physician rcportetl I)lood count was
remora1
to
my the
weight.
painless
of extraction there was adrenalin rlrlorillr packs
point was both
at
jaw;
three teeth at one sitting, and hospitalizetl the patient for removal contents of the cyst were infected and a creamy, yellow pus was stutly of the cystic \~-a11 was not obtainecl.
as the 111an(li1dr lower rrptorati,jn, palpable.
presentetl
the
lower left was a nonvital
submaxillarg
all!-ise,cl
in
hypertrophy bleeding.
molar
referrwl
menf.--J
than The microsropic
of
Ovcrhxnging the gum margin
an11 urindgsis. The ant1 the tlifierential minutes.
After e:tcll wrirs t:tnnic ac+ill :tncl
more
ancl
slight of
Diczgnos,‘s.-Tnfl:~~~~~~~~tory Brent
soft
revealecl witlenve
lS,rflnLinntiow-I
tial l~lootl connt, were negative, time to be four
a loss
B.rnmi~m~f iox-Generalized ant1 the mantlil)le. The
The lower cyst at
a printer,
esanlination showetl market1 slight swelling of the ones
and
am1 was gootl.
examination There was
was
swelling
sitle.
tired,
not fixetl, stjikingly
CASE
previous to the examination. told that hc was healthy
was
constantly
was was
who was
A
patient was referred to He had notiwtl gratlud
Clin’iccd Bromination.--F,str:~or:~l maxillary chain of lymph notles, on the left appearance
years,
complaint
Hislwy.-l’llr of thr gums. the six months
three
plainecl
His
irritate11
U2lrdicnZ of pyorrhea notles tluring least
nude,
6, 1939.
OF
ant1
his
regression tlw time chain of l~lrysicd
I was
necessary extracted
of the cyst. evacuated.
A
of the submxxill:try we hegxn the work nodes were only just
swelling on the slightly
appearawe
grwtly.
improrecl
The patient promiseti to return I set the complete lower denture on Dec. 12, 1939. very soon for the work in the maxilla. I did not see him sgain until Jan. 4, 1941, at which time hr returned to my office with x recurrence of the submaxillary swelling, increasing Examination at this time &owe<1 a bilateral lymplmdenopatl~y pallor, and loss of weight. of the sulxnasillary, cervical, and axillary notlrs. I real&et1 this contlition another examination for tlifferential or leucemix.
was
not due to any inflammatory process and ,tliagnosis of tuberculous lymphadenitis, Hodgkin’s
Vrtlicnl Bepod.-On Jan. 21. 1941, the patient’s 9:‘: per cent; l~rrnoglot~in, cnbic centimeter ; lymphocytes, was enlargetl to the region of the pubis. nirrg7zosis.~Clironic Trrntnwnt.-Deep
lymphatic s-ray
requested disease,
white blood count was 376,000 per (ii per cent. The patient’s spleen
lcurrmia.
therapy.
The last report I hart of this patient’s 1941, at whirh time the count hat1 droppe(l to SF) per cent and hemoglobin 54 per cent.
white 85,800
The prognosis is, of course, Cases with a history of twenty occurring from unrelated causes.
However, the course may pears have been rcportetl,
unfavorable. to twenty-five
blood cell count was that per cubic centimeter, with
of Feb. lymphocytes
ti,
be quite prolonged. with death finally
This case is presented because of its interest to both the medical and dental professions. The necessity of close cooperation between the medical and dental professions is evident. It, is axiomatic in medicine that the cause of a disease must he known and understood before a cure car1 be effected. It is equally patent that this applies to dent,ist.ry. The relationship of the oral pathologic conditions to the systemic disease is quite obvious. Complete laboratory examination by a competent physician is helpful, and :I careful follow-up therapy and examination are important. REFERENCES I<. H.: Oral Diagnosis ant1 Treatment Planning, Philadelphia, 1936, W. B. Sauntler* Co., pp. 239-240. 2. Forkner, (‘laude E.: J,eukemix and Allied Disorders, Kew York, 1938, Macmillan, pp. 75.in. 2. Hayes, Id. V.: Clinical Diagnosis of Diseases of the Mouth, 1936, Dent. Items of Int. Publishing Co., Inc., pp. 44-45. 4. Meatl, S. V.: Diseases of the Mouth, St. Louis, 1940, The C. V. Mosby Co., p. 489. I.
Thoma,
i13
BKOADWAY
LYMPHATIC REPORT
IV.
N.
BURFORD,
OF
LEUCERIIA A
D.D.S.,
CASE COLKVIBIA,
110.
A
FACT that is being constantly overlooked by all of us is the relation of We, as dentists, have long been chided for the mouth to the entire body. our failure to see beyond the cavities in the teeth and the edentulous areas. Regretfully, we have to admit to such criticism because of our purely mechanical Personally, I think the restorative side of dentistry interest in the oral cavity. has reached a point of saturation and we would do well to let it rest upon its laurels for a time. Our future interests and advancements should be concerned with the health of the soft tissues of the mouth and the relation of these tissues to the health of the entire body. A great, many systemic disorders manifest themselves within the oral cavity at one time during their clinical course. This manifestation may be as evident Most diseases of this as the mucous patches of syphilis, or it may be obscure. type are insidious and, therefore, difficult to recognize at a time when recognition is most important. But, we should feel it our dut,y to become so well informed that very little within the mouth will be missed. It is not my purpose to list all systcrnic diseases we may expect to see manifested in the mouth. I wish to present only one case, and I will cndeavor to prove how important early recognition upon the part of the dentist can be. Leuccmia is an invariably fatal systemic disease of unknown etiology, priAt first marily involving the blood-forming organs, among them the spleen. glance, I can think of nothing more removed from our field than the human spleen. However, its action will place us squarely in the clinical picture of all types of leucemia. One of the most important clinical signs of any type of lencemia is the diffuse, marked swelling of the mucous membra.nes of the mouth and upper respiratory tract. This swelling is associated with a tendency of these membranes to hemorrhage. Gingivae will bleed at such insignificant trauma as toothbrushing. Hypertrophy of the gums. especially at the interdental spaces, plus the bleeding I have mentioned, presents a picture closely simulating simple gingivitis. I have seen some cases, and the case I am presenting is one of them, diagnosed as p>-orrhea. I am certain a more thorough examination of the patients, on our part, will make for less careless diagnoses. The diffuse marked swelling of the mucous membranes, and the increased tendency to bleed, is sometimes the initial symptom which causes patients to Because of the nature of this complaint, a large major*seek professional advice. it>- of such pat,ients first consult their dentist. The latter must exercise every caution because it frequently happens that he does not realize the seriousness of Oral
Surgeon
to
Ellis
Fischel
State
Cancer 549
Hospital.
Columbia,
Mo.
lhc situation, and may make one or more extractions, which may be followed by uncontrollable hemorrhage, ulcer&ion, and in some cases, osteomyelitis. Farreul and Landais (1931), Pollosson and Lebeuf (1933), and others have reported the occurrence of noma, or gangrenous stomatitis, following the ext,raction of a tooth in patient,s with leucemia. Forkner (1934) showed that in each of six eases of acute monocytic leuccmia the patients’ first complaints were swelling of the gingivae with subsequent ulceration and necrosis. Each of these paCents first consulted dentists before finally consulting their physician. Chronic lymphatic leuccmia represents the largest group numerically of all leucemias. This includes the typical rasc usuallspoken of as lymphatic leucemia with l~rn~~,haclerloI)atfl~ and moderate splenomegalp, moderate anemia and marked elevation of the total white blood cell count, consisting almost entirely of Iymphocytcs. REPORT J.
II.,
on March was
a white
sliglltly
on
physicians
of
age{1 chief thp
being
ant1
40
left
dental
Tntroor:rl spaces.
with
crown
of
the
lower
left
Bornt
of
cddus
Mrdicnl
no first
was
startetl able to to
use
molar
tlestrojwl,
right first the apes. present
extractions finish only
on March the lower
An
left
himself
sitlr
of
the
in~purtant
my
at
o&e by enlargement
on
his of
the
of
physician the left
He stated an11 perfectly
he all
the
of roots
the teeth
Thr
llatient
at
the
gums were
gainer1
been to at He com-
of the left right. The patient’s
especially clecayetl,
resorption first
subma,99
general
at tlirty,
the interwith the
of
the
alveolus
molar roots presented tooth, with a well-tlefinecl,
were lower
seen on anterior
to his
physician
for
that within
the Kahn normal
all fillings, teeth. a Kahn
was
evidence rather ant1
test,
an
tlifferen-
reaction and urinalysis limits and the cdlotting
lynlphatlenitis. all
teeth
with the
careful poor
curettage rooperaticm
of
the
of
the
time
weight
sockets. patient,
copious ljleetling, am1 twicse it ~2s to arws;t the hemorrhage. I never
was
the
Ry c*lewnwl of its pathology. the right and left sul~maxillx~~p steallily
for treatment submaxillary
had right.
The
margins of the
16, 1929, ant1 tine to jaw by Oct. 20, lR3.
me
office tongue
remaining.
horizontal
patient
swelling on the
manipulation.
The
physician rcportetl I)lood count was
remora1
to
my the
weight.
painless
of extraction there was adrenalin rlrlorillr packs
point was both
at
jaw;
three teeth at one sitting, and hospitalizetl the patient for removal contents of the cyst were infected and a creamy, yellow pus was stutly of the cystic \~-a11 was not obtainecl.
as the 111an(li1dr lower rrptorati,jn, palpable.
presentetl
the
lower left was a nonvital
submaxillarg
all!-ise,cl
in
hypertrophy bleeding.
molar
referrwl
menf.--J
than The microsropic
of
Ovcrhxnging the gum margin
an11 urindgsis. The ant1 the tlifierential minutes.
After e:tcll wrirs t:tnnic ac+ill :tncl
more
ancl
slight of
Diczgnos,‘s.-Tnfl:~~~~~~~~tory Brent
soft
revealecl witlenve
lS,rflnLinntiow-I
tial l~lootl connt, were negative, time to be four
a loss
B.rnmi~m~f iox-Generalized ant1 the mantlil)le. The
The lower cyst at
a printer,
esanlination showetl market1 slight swelling of the ones
and
am1 was gootl.
examination There was
was
swelling
sitle.
tired,
not fixetl, stjikingly
CASE
previous to the examination. told that hc was healthy
was
constantly
was was
who was
A
patient was referred to He had notiwtl gratlud
Clin’iccd Bromination.--F,str:~or:~l maxillary chain of lymph notles, on the left appearance
years,
complaint
Hislwy.-l’llr of thr gums. the six months
three
plainecl
His
irritate11
U2lrdicnZ of pyorrhea notles tluring least
nude,
6, 1939.
OF
ant1
his
regression tlw time chain of l~lrysicd
I was
necessary extracted
of the cyst. evacuated.
A
of the submxxill:try we hegxn the work nodes were only just
swelling on the slightly
appearawe
grwtly.
improrecl
The patient promiseti to return I set the complete lower denture on Dec. 12, 1939. very soon for the work in the maxilla. I did not see him sgain until Jan. 4, 1941, at which time hr returned to my office with x recurrence of the submaxillary swelling, increasing Examination at this time &owe<1 a bilateral lymplmdenopatl~y pallor, and loss of weight. of the sulxnasillary, cervical, and axillary notlrs. I real&et1 this contlition another examination for tlifferential or leucemix.
was
not due to any inflammatory process and ,tliagnosis of tuberculous lymphadenitis, Hodgkin’s
Vrtlicnl Bepod.-On Jan. 21. 1941, the patient’s 9:‘: per cent; l~rrnoglot~in, cnbic centimeter ; lymphocytes, was enlargetl to the region of the pubis. nirrg7zosis.~Clironic Trrntnwnt.-Deep
lymphatic s-ray
requested disease,
white blood count was 376,000 per (ii per cent. The patient’s spleen
lcurrmia.
therapy.
The last report I hart of this patient’s 1941, at whirh time the count hat1 droppe(l to SF) per cent and hemoglobin 54 per cent.
white 85,800
The prognosis is, of course, Cases with a history of twenty occurring from unrelated causes.
However, the course may pears have been rcportetl,
unfavorable. to twenty-five
blood cell count was that per cubic centimeter, with
of Feb. lymphocytes
ti,
be quite prolonged. with death finally
This case is presented because of its interest to both the medical and dental professions. The necessity of close cooperation between the medical and dental professions is evident. It, is axiomatic in medicine that the cause of a disease must he known and understood before a cure car1 be effected. It is equally patent that this applies to dent,ist.ry. The relationship of the oral pathologic conditions to the systemic disease is quite obvious. Complete laboratory examination by a competent physician is helpful, and :I careful follow-up therapy and examination are important. REFERENCES I<. H.: Oral Diagnosis ant1 Treatment Planning, Philadelphia, 1936, W. B. Sauntler* Co., pp. 239-240. 2. Forkner, (‘laude E.: J,eukemix and Allied Disorders, Kew York, 1938, Macmillan, pp. 75.in. 2. Hayes, Id. V.: Clinical Diagnosis of Diseases of the Mouth, 1936, Dent. Items of Int. Publishing Co., Inc., pp. 44-45. 4. Meatl, S. V.: Diseases of the Mouth, St. Louis, 1940, The C. V. Mosby Co., p. 489. I.
Thoma,
i13
BKOADWAY