Multiple myeloma / dental implant courses

www.indiandentalacademy.com

INDIAN DENTAL ACADEMYLeader in continuing Dental Education

Chief complaint

A 67 year old female

reported with a chief

complaint of –

A painful swelling on the right side of the face since 1 month.


HistoryHistory HOPI

History dates back to 1 month,when patient noticed a rapidly increasing swelling on right side of face

Concurrent intraoral growth on same side of jaw.

Pain and difficulty in eating.

Malaise and weakness

No history of pus discharge

Past Medical History - Non contributory

Past Dental history - Non contributorywww.indiandentalacademy.com

Clinical Examination

General examination:-

Patient was irritable

Pallor was present.


Extraoral Examination

Facial asymmetry

Single,Diffuse,tender &

firm swelling

Overlying skin normal but

stretched.

TMJ movement restricted

on right side

No lymphadenopathywww.indiandentalacademy.com

Extraoral Examination…

Extension –

Superioinferiorly - From the level of outer canthus of eye to submandibular region

Anteroposteriorly - From right corner of mouth to the tragus


Intra-oral Examination

Reduced mouth opening

Localized swelling on

46,47,48

Extension-

Anteroposteriorly from 45 to retromolar region

Superoinferiorly from above occlusal level of teeth to lower buccal vestibule.


Smooth surfaced, lobulated, erythematous

& covered with pale necrotic slough at few

areas

Tender, soft to firm, non-pulsatile swelling

Grade III mobility – 43,44,45

Intra-oral Examination…


Radiographic Examination

ORTHOPANTOGRAM

Large osteolytic lesion of Rt. ramus

Multiple punched out radiolucencies

Diffuse generalized rarefaction

Pathological fracture at subcondylar level

Soft tissue shadow in Rt. ramus


Radiographic examinations …


Differential Diagnosis

Multiple Myeloma

Metastatic carcinoma of jaw

Intraosseous malignant neoplasm

Salivary gland malignant neoplasm

Generalized rarefaction of bone may be due to lesion itself or

separate condition like Osteoporosis/ Hyperparathyroidism


Investigation ?


Further investigation performed

1. Radiographic skeletal survey– Lateral skull view– PA view– Chest radiograph– Vertebrae radiograph– Pelvis radiograph

2. Color Doppler USG

3. CT scan

4. Biochemical Investigations

5. Histopathology www.indiandentalacademy.com

NUMEROUS PUNCHED OUT NUMEROUS PUNCHED OUT LYTIC LYTIC LESIONS IN WHOLE LESIONS IN WHOLE SKULLSKULL


MULTIPLE LYTIC LESIONS IN MULTIPLE LYTIC LESIONS IN

CLAVICLESCLAVICLES


COLLAPSE OFCOLLAPSE OFT7,T8 T7,T8

VERTEBRAL VERTEBRAL BODIES BODIES

LYTIC LESIONS IN LYTIC LESIONS IN PELVIS PELVIS


Color Doppler USG

STRONGLY VASCULAR MIXED STRONGLY VASCULAR MIXED ECHOGENIC LESIONECHOGENIC LESION


CT

GROSS BONE DESTRUCTION WITH GROSS BONE DESTRUCTION WITH SOFT SOFT

TISSUE MASSTISSUE MASSwww.indiandentalacademy.com

PLAIN & CONTRAST CTPLAIN & CONTRAST CT

LARGE SOFT TISSUE LESION LARGE SOFT TISSUE LESION SHOWINGSHOWING

STRONG CONTRAST ENHANCEMENT STRONG CONTRAST ENHANCEMENT www.indiandentalacademy.com

PUNCHED OUT LYTIC LESIONS IN PUNCHED OUT LYTIC LESIONS IN THE SKULL INVOLVING BOTH THE SKULL INVOLVING BOTH TABLESTABLES


VRT VRT IMAGEIMAGE


Biochemical Investigations

Hb - 6.6 gm %

Urine analysis – Bence Jones protein present

Serum Calcium level – 13 mg /100 ml


Histopathological examination

Section stained with H&E reveals sheets of plasma cells showing nuclear

pleomorphism & lymphocytes, suggestive of PLASMACYTOMA.


Multiple Myeloma Multiple Myeloma

Final Diagnosis


Discussion

We Fear Things in We Fear Things in Proportion To Our Proportion To Our

Ignorance Of Ignorance Of Them. Knowledge Them. Knowledge Is The Antidote To Is The Antidote To

Fear. Fear.

-Emerson-Emerson


Multifocal neoplasm that stem from the bone

marrow

Characterised by abnormal proliferation of plasma cells

& produce a monoclonal immunoglobulin ( M protein )

Second most prevalent blood cancer and 10% -15 % of

all hematological malignancies

Approx. 1% of all cancers causing & 2% of all cancer

death.www.indiandentalacademy.com

Unknown Etiology

Suspected Risk FactorDecline in the immune system

Occupations – Agriculture, wood, leather,

paint industry worker

Chemicals Exposure – DDT, Benzene

Radiation Exposure

Virus – HHV8


29

Pathogenesis


Discussion…

Incidence: 3 - 9 cases per 1,00,000 population / year Modest male predominance More frequent in elderly

Site: Skull, vertebrae, mandible, pelvis, sternum, clavicle,humerus and femur


Clinical Features :

Bone pain & Pathologic fractures

Weakness and fatigue

Anaemia

Severe infection

Renal failure

Weight loss

Numbness in limbswww.indiandentalacademy.com

Multiple Myeloma in the jaws

The incidence of the oral lesions in multiple myeloma varies from less than 2% to 70%.

8% to 15% incidence of Jaw lesion as a primaryprimary

manifestationmanifestation of multiple myeloma

Site of active hematopoiesis - Mandible angle, Mandible angle, ramus and premolar molar regionramus and premolar molar region

Dentomaxillofacial Radiology (2004) 33, 413-419


Clinical features in oral cavityPain & Swelling

Paresthesia

Soft tissue mass

Pathological fracture

Tooth mobility & migration

Haemorrhage

Amyloid deposition in the tongue & other oral tissues.

Presence of one or more of these features in jaws may be an initial clue to diagnosis of multiple myeloma.


Radiographic features1. Punched-out radiolucencies without sclerotic borders

2. Radiolucent lesions

3. Osteoporotic

4. Rarely Osteosclerotic changes

Skeletal involvement may manifest as punched-out lesions with variable degree of osteoporosis, but the combination of punched-out lesions with osteoporotic appearance is rarely reported in mandibular involvement, as seen in this case


Diagnostic Criteria Major criteria I. Plasmacytoma on tissue biopsy

II. Bone marrow plasma cell > 30%

III. Monoclonal M spike on electrophoresis / Bence Jones protein in 24h urine sample

Minor criteriaa. Bone marrow plasma cells 10-30%

b. M spike but less than above

c. Lytic bone lesions

d. Normal IgM < 50mg, IgA < 100mg, IgG < 600mg/dlwww.indiandentalacademy.com

Conventional chemotherapyMelphlan + Prednisone

Supportive treatment Biphosphonates, calcitonin Recombinant erythropoietin Immunoglobulins Plasma exchange Radiation therapy

Management


Although the initial features of multiple myeloma are variable & rarely appears in the jaw, this disease should be borne in mind as a differential diagnosis

Careful examination of the patient including radiographic imaging should be undertaken.

Hence improving the life expectancy and

the quality of life…www.indiandentalacademy.com

Multiple myeloma / dental implant courses

Education

Transcript of Multiple myeloma / dental implant courses