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 Table of Contents  
Year : 2021  |  Volume : 16  |  Issue : 1  |  Page : 209-211

Chronic myeloid leukemia manifesting as uncontrolled posttooth extraction hemorrhage: A rare case report

1 Department of Oral and Maxillofacial Surgery, A B Shetty Memorial Institute of Dental Sciences, Mangalore, Karnataka, India
2 Department of Pathology, K S Hegde Medical Academy of Nitte University, Mangalore, Karnataka, India

Date of Submission17-Jul-2020
Date of Decision24-Nov-2020
Date of Acceptance26-Nov-2020
Date of Web Publication29-Jul-2021

Correspondence Address:
Dr. Kishan Prasad Hosapatna Laxminarayana
Department of Pathology, K S Hegde Medical Academy of Nitte University, Mangalore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_272_20

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Postoperative bleeding is one of the common complications encountered in dental practice after routine dental extractions. Preoperative assessment of the patient is an integral aspect of managing and delivering dental care effectively to a patient. However, a patient with unknown and previously undiagnosed systemic illness can further complicate the treatment and result in defective hemostasis postextraction. We report a rare case of a 23-year-old male, who was diagnosed with chronic myeloid leukemia following uncontrolled hemorrhage postsimple dental extraction procedure.

Keywords: Complication, extraction, hemorrhage, hemostasis, leukemia, myeloid

How to cite this article:
Samuel S, Bhal D, Chandran T, Laxminarayana KP. Chronic myeloid leukemia manifesting as uncontrolled posttooth extraction hemorrhage: A rare case report. J Datta Meghe Inst Med Sci Univ 2021;16:209-11

How to cite this URL:
Samuel S, Bhal D, Chandran T, Laxminarayana KP. Chronic myeloid leukemia manifesting as uncontrolled posttooth extraction hemorrhage: A rare case report. J Datta Meghe Inst Med Sci Univ [serial online] 2021 [cited 2021 Sep 23];16:209-11. Available from: http://www.journaldmims.com/text.asp?2021/16/1/209/322623

  Introduction Top

Extraction is a common and routine dental procedure undertaken in a clinical dental setting. It has several complications associated with it, postextraction bleeding being the most common.[1],[2] Proper hemostasis needs to be achieved after extraction to avoid the incidence of postextraction hemorrhage.[3] Few systemic diseases can manifest with postextraction bleeding. These can be avoided with a proper perioperative assessment of the patient, including obtaining a detailed case history to rule out any systemic conditions, which might aggravate the risk of bleeding.

Dentists at times can be the first one to diagnose an unknown underlying medical condition, which the patient might not be aware of the illness. Leukemia is a group of hematopoietic disorders, characterized by abnormal differentiation and proliferation of white blood cells (WBCs) manifesting with fever, anemia, bleeding, petechiae, thrombocytopenia, etc.[4],[5],[6] Chronic myeloid leukemia is a rare type, commonly with a molecular translocation between chromosomes t (9;22) (q34; q11) which results in the formation of BCR–ABL gene fusion.[7] There is evidence of hyperfibrinolysis in patients with leukemia, which contributes to unexplained bleeding episodes.[8] We are reporting the rare case of a patient who was diagnosed with chronic myeloid leukemia after uncontrolled hemorrhage after simple dental extraction.

  Case Report Top

A 23-year-old, male presented with uncontrolled and excessive bleeding from the left upper back teeth region. On history, it was found that he had undergone extraction of upper left second premolar the previous day at a rural center. The tooth was removed due to chronic irreversible pulpitis, and a pressure pack was given to patient postextraction along with antibiotics and analgesics. However, after 3 h, the patient noticed bleeding from the extraction socket and managed by a local hospital with a pressure pack and was referred to our hospital for further management. The case was reviewed with a complete case history followed by a thorough intraoral examination. Past history was unremarkable. On intraoral examination of the socket, bleeding was evident from minor spaces in the socket. Tight suturing of the extraction socket was done to control the bleeding. After suturing, perio pack was placed, and the patient was asked to bite tightly on it for at least an hour.

The proper hemostasis was achieved. The patient was then admitted to hospital for further investigations to diagnose the underlying cause for uncontrolled bleeding. Laboratory investigation showed hemoglobin of 9.3G/dl, and the total leukocyte count was 193,600 cells/cumm (high). The peripheral smear showed a marked increase in WBCs with an absolute increase in myeloid precursors there were myeloblasts – 02%, promyelocytes – 07%, metamyelocytes – 16%, myelocytes – 09%, band forms – 10%, neutrophils – 48%, lymphocytes – 04%, eosinophils – 02%, and basophils – 02% [Figure 1]. On physical examination, massive splenomegaly was also noted. Thus, he was diagnosed with CHRONIC MYELOID LEUKEMIA-CHRONIC PHASE. There were no other oral signs suggestive of the disease. His bleeding was managed conservatively. The patient was advised, counseled for further management for chronic myeloid leukemia and referred to the tertiary center for further treatment.
Figure 1: Peripheral smear showing chronic myeloid leukemia in chronic phase (×400, Leishman)

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  Discussion Top

The postextraction bleeding can pose a significant problem and can be distressing even after a simple routine dental extraction, both the patient as well as the dentist.[9] It is therefore essential to have proper knowledge about the physiological process of hemostasis and the factors, which can cause alteration in this mechanism. Obtaining a detailed case history, preoperative investigations, and evaluation of patients before minor oral surgical procedures can reduce the risk of postoperative complications. Myelodysplastic and myeloproliferative diseases can make the patient prone to excessive bleeding tendencies. Chronic myeloid leukemia is characterized by myeloid hyperplasia with polymorphonuclear leukocytosis, splenomegaly, and anemia and can lead to a fatal blast crisis.[5] It has been found that increased plasma urokinase-type plasminogen activator receptor is a contributing factor to abnormally high fibrinolytic activity resulting in bleeding in leukemic patients.[8] Dentists should, therefore, be equipped to manage any bleeding episodes occurring in the outpatient department. Local hemostatic agents' pressure can do the management of uncontrolled bleeding, surgical packs, sutures, and surgical stents.[10] Fever and organomegaly are other standard features associated with this type of leukemia.[11]

Tiwari et al. in 2018 reported a case of postextraction bleeding being diagnosed as acute myeloblastic leukemia..[12]

A study in 2009 by Suárez-Cuenca et al. reported an unusual case of acute promyelocytic leukemia, which initially came as pain in the third molar following extraction of which patient had bleeding episodes and poor healing, later resulting in the death of the patient due to intracranial bleeding secondary to disseminated intravascular coagulation.[13]

Pinheiro reported a rare case of reactionary bleeding after the extraction of the mandibular canine tooth. After necessary investigations, the patient was diagnosed with acute promyelocytic leukemia.[14]

Chronic myeloid leukemia presenting with postextraction bleeding is very rare.

Hence, it is essential that dentists have a strong clinical and a dental surgeon first identifies diagnostic acumen as many underlying and undiagnosed systemic diseases. This can help the clinicians avert the many unwanted complications encountered in a dental office and can enhance patient care, thereby highly improving the patient compliance toward dental treatment.

  Conclusion Top

An episode of uncontrolled bleeding after extraction should always alert the dental surgeon of an underlying systemic condition so that the disease can be diagnosed, and the patient management and treatment is more effective. Preoperative assessment is a necessary and crucial aspect of planning treatment for any patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Guo S, Dipietro LA. Factors affecting wound healing. J Dent Res 2010;89:219-29.  Back to cited text no. 3
Wu J, Fantasia JE, Kaplan R. Oral manifestations of acute myelomonocytic leukemia: A case report and review of the classification of leukemias. J Periodontol 2002;73: 664-8.  Back to cited text no. 4
Jacobs P. Myelodysplasia and the leukemias. Dis Mon 1997;43:505-97.  Back to cited text no. 5
Rose-Inman H, Kuehl D. Acute leukemia. Hematol Oncol Clin North Am. 2017;31:1011-28.  Back to cited text no. 6
Flis S, Chojnacki T. Chronic myelogenous leukemia, a still unsolved problem: Pitfalls and new therapeutic possibilities. Drug Des Devel Ther 2019;13:825-43.  Back to cited text no. 7
Wang P, Zhang Y, Yang H, Hou W, Jin B, Hou J, et al. Characteristics of fibrinolytic disorders in acute promyelocytic leukemia. Hematology 2018;23:756-64.  Back to cited text no. 8
Leonard MS. An approach to some dilemmas and complications of office oral surgery. Aust Dent J 1995;40:159-63.  Back to cited text no. 9
Gupta A, Epstein JB, Cabay RJ. Bleeding disorders of importance in dental care and related patient management. J Can Dent Assoc 2007;73:77-83.  Back to cited text no. 10
Hou GL, Huang JS, Tsai CC. Analysis of oral manifestations of leukemia: A retrospective study. Oral Dis 1997;3:31-8.  Back to cited text no. 11
Tiwari R, Mathew P, Tiwari H, Sherawat K, Kaswan U, Roy B. Massive bleeding post tooth extraction diagnosed with acute myeloblastic leukemia: A case report. Int J Appl Dent Sci 2018;4:225-7.  Back to cited text no. 12
Suárez-Cuenca JA, Arellano-Sánchez JL, Scherling-Ocampo AA, Sánchez-Hernández G, Pérez-Guevara D, Chalapud-Revelo JR. Rapidly progressing, fatal and acute promyelocytic leukaemia that initially manifested as a painful third molar: A case report. J Med Case Rep 2009;3:102.  Back to cited text no. 13
Pinheiro RT. Diagnosis of acute promyelocytic leukemia after complication of dental procedure: Case report. Odontol Clín-Cient 2011;10:85-7.  Back to cited text no. 14


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