Carranza’s Clinical Periodontology, 12th Ed, Chapter 18

Figure 18-15: A 12 year-old boy with acute lymphoblastic leukemia. There is generalized redness of the marginal gingiva, with spontaneous bleeding.

This image reminds us not to assume that plaque biofilm is always the etiological factor in gingival inflammation.  The teeth seen in this image appear relatively plaque free, but had this inflammation also been accompanied by plaque biofilm deposits, the assumption would have been plaque-related inflammation.  Underscoring why a follow-up visit is critical, the astute clinician would realize after plaque biofilm control was instituted, that there must be a different etiological factor.  In fact, leukemia is the most common childhood cancer and leading cause of cancer death in children.  According to The American Cancer Society, leukemia cells building up in the marrow crowd out normal red blood cells, white blood cell, and blood platelets.  They suggest that a shortage of platelets can lead to ‘bleeding gums’1.  Let us remember to remain vigilant in what we see and decide about tissue appearance.