multiple myeloma / dental implant courses
TRANSCRIPT
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INDIAN DENTAL ACADEMYLeader in continuing Dental Education
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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.
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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
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Clinical Examination
General examination:-
Patient was irritable
Pallor was present.
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Extraoral Examination
Facial asymmetry
Single,Diffuse,tender &
firm swelling
Overlying skin normal but
stretched.
TMJ movement restricted
on right side
No lymphadenopathywww.indiandentalacademy.com
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Extraoral Examination…
Extension –
Superioinferiorly - From the level of outer canthus of eye to submandibular region
Anteroposteriorly - From right corner of mouth to the tragus
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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.
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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…
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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
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Radiographic examinations …
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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
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Investigation ?
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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
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NUMEROUS PUNCHED OUT NUMEROUS PUNCHED OUT LYTIC LYTIC LESIONS IN WHOLE LESIONS IN WHOLE SKULLSKULL
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MULTIPLE LYTIC LESIONS IN MULTIPLE LYTIC LESIONS IN
CLAVICLESCLAVICLES
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COLLAPSE OFCOLLAPSE OFT7,T8 T7,T8
VERTEBRAL VERTEBRAL BODIES BODIES
LYTIC LESIONS IN LYTIC LESIONS IN PELVIS PELVIS
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Color Doppler USG
STRONGLY VASCULAR MIXED STRONGLY VASCULAR MIXED ECHOGENIC LESIONECHOGENIC LESION
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CT
GROSS BONE DESTRUCTION WITH GROSS BONE DESTRUCTION WITH SOFT SOFT
TISSUE MASSTISSUE MASSwww.indiandentalacademy.com
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PLAIN & CONTRAST CTPLAIN & CONTRAST CT
LARGE SOFT TISSUE LESION LARGE SOFT TISSUE LESION SHOWINGSHOWING
STRONG CONTRAST ENHANCEMENT STRONG CONTRAST ENHANCEMENT www.indiandentalacademy.com
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PUNCHED OUT LYTIC LESIONS IN PUNCHED OUT LYTIC LESIONS IN THE SKULL INVOLVING BOTH THE SKULL INVOLVING BOTH TABLESTABLES
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VRT VRT IMAGEIMAGE
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Biochemical Investigations
Hb - 6.6 gm %
Urine analysis – Bence Jones protein present
Serum Calcium level – 13 mg /100 ml
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Histopathological examination
Section stained with H&E reveals sheets of plasma cells showing nuclear
pleomorphism & lymphocytes, suggestive of PLASMACYTOMA.
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Multiple Myeloma Multiple Myeloma
Final Diagnosis
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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
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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
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Unknown Etiology
Suspected Risk FactorDecline in the immune system
Occupations – Agriculture, wood, leather,
paint industry worker
Chemicals Exposure – DDT, Benzene
Radiation Exposure
Virus – HHV8
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29
Pathogenesis
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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
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Clinical Features :
Bone pain & Pathologic fractures
Weakness and fatigue
Anaemia
Severe infection
Renal failure
Weight loss
Numbness in limbswww.indiandentalacademy.com
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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
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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.
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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
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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
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Conventional chemotherapyMelphlan + Prednisone
Supportive treatment Biphosphonates, calcitonin Recombinant erythropoietin Immunoglobulins Plasma exchange Radiation therapy
Management
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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
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