Oral Necrotizing Ulcerations in Acute Leukemia Patients: Clinical Characteristics, Integrated Management, and Favorable Outcomes – A Case Series

Introduction: Leukemia often presents with diverse oral manifestations like ulceration, bleeding, and gingival enlargement due to immunosuppression and chemotherapy. The altered oral microbiome in leukemic patients increases infection risks, including bloodstream infections. Early diagnosis and targeted treatment of oral complications are vital to improve patient outcomes and quality of life. Purpose: This case series aims to explore the clinical presentation, underlying systemic conditions, and treatment response of oral necrotizing ulcerations including necrotizing ulcerative gingivitis (NUG) and necrotizing stomatitis in patients with acute leukemia. Patients and Methods: Three female patients aged 18 to 21 years were diagnosed with necrotizing ulcerative oral lesions associated with acute leukemia: two with Acute Lymphoblastic Leukemia (ALL) and one with Acute Myeloid Leukemia (AML). Detailed intraoral examinations were performed, alongside hematologic and biochemical laboratory analyses. Treatment protocols included gingival debridement with hydrogen peroxide 1,5%-3%, chlorine dioxide zinc antiseptic mouthwashes (chlorine dioxide zinc), topical hyaluronic acid, and Vaseline application. Suggestions of prescribing Metronidazole also been given to the referring departments. Patients were monitored through serial follow-ups for clinical progress. Results: All three patients presented with crater-like ulcerations, greyish pseudomembranes, and gingival inflammation, with varying degrees of systemic hematologic compromise. The first patient (ALL) showed marked improvement by the third follow-up, with near-complete healing by the final visit. The second patient (AML) demonstrated reduction in gingival necrosis and inflammation, although gingival hyperplasia persisted. The third patient (ALL, pre-chemotherapy) initially presented with necrotizing stomatitis and NUG; significant clinical improvement and complete lesion resolution were observed over successive follow-ups. Systemic findings, including leukopenia, anemia, and elevated inflammatory markers, were consistent with hematologic malignancies and contributed to lesion severity. Our incapability to perform additional diagnostic test such as oral lesion biopsy or microbiology test was the limitations of this case report. Conclusion: Oral Necrotizing Ulcerations, including NUG, NUP, and NUS, represent significant clinical manifestations of acute leukemia, reflecting the underlying immunosuppression, hematologic abnormalities, and oral microbial dysbiosis inherent to the disease. Early recognition of characteristic clinical features, followed by integrated local oral management and close coordination with systemic medical care, can lead to favorable healing outcomes despite profound hematologic compromise. Keywords: necrotizing ulcerative gingivitis, acute leukemia, oral ulcerations