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1. GOOD
MORNING
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2. DR. LALITHA
P.G. STUDENT
DEPT OF ORAL MEDICINE & RADIOLOGY
MEDICAL MANAGEMENT UPDATE
MULTIPLE MYELOMA
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3. ERIC T. STOOPLER, EDWARD A. STADTMAUER, PHILADELPHIA
UNIVERSITY OF PENNSYLVANIA
OOOOEndo 2007;103:599-609
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4. MULTIPLE MYELOMA
B-cell malignancy characterised by
abnormal proliferation of plasma cells able to
produce a monoclonal immunoglobulin ( M
protein )
15000 cases /yr
Older adults (65yr)
Exposed to radiation, Pesticides, and Herbicides
Pt with Monoclonal Gammopathy of Undetermined
Significance (MGUS)
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5. ETIOLOGY/Pathogenesis
B-cell Plasmablasts
DNA recombination changes
Somatic hypermutation &IgGHeavy chain switching
specific individual Immunoglobulins
Pathologic chromosomal translocation IgG locus on
chromosome 14
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6. CLINICAL PRESENTATION
Bone pain - Lumbar vertebrae
Fractures, Spinal cord compression
Hypercalcemia- confusion, bonepain
Infections – Haemophilus influenzae
Petechial hemorrhages of skin , oral mucosa
Fever – Neutropenia
Metastatic calcifications – Hypercalcemia
Amyloid deposition – soft tissues
Tongue, Periorbital skin – waxy, firm plaque like
lesions
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8. Plasma cell Neoplasia
Oral/ Maxillofacial manifests as
1. Local manifestation of MM
2.Solitary bone plasmacytoma
3.Extra madeullary plasmacytoma
Plasmacytoma – Neoplastic proliferation of plasma
cells localized to either bone or soft tissue
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9. ORAL MANIFESTATIONS
Initial presenting sign of disease
Tooth ache, tooth mobility and migration
Mucosal ulcerations, soft tissue swelling, paresthesia
due to nerve compression
Gingival bleeding/ hemorrhage
Acquired Von Willebrand’s disease (thrombin
factor)
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11. RADIOGRAPHIC
MM- Multiple punched out radiolucencies
More common posterior mandible
I.O.P.A- Periodontal destruction, root resorption
Intraosseous expansion, pathological fracture
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13. SKULL
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14. PA VIEW OF SKULL
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15. Ribs and Humerus
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16. Criteria For DIAGNOSIS Of MM
Symptomatic MM
Clonal plsma cells – biopsy of bone marrow
M- protein in serum or urine
Evidence of related organ or tissue impairment
Asymptomatic(smoldering myeloma)
Serum M protein 3> g/dl & or Clonal plasma
cells>10% of bone marrow
No symptoms or evidence ofrelated organ
impairement
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17. Monoclonal Gammopathy of Undetermined
significance (MGUS)
Serum M protein < 3g/dl
Bone marrow plasma cells<10% of aspirate
No symptoms or evidence of related organ o tissue
impairement
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18. Multiple Myeloma
Laboratory tests:
ESR > 100
anaemia, thrombocytopenia
marrow plasmacytosis > 10 -15%
hyperproteinemia
hypercalcemia
proteinuria
azotemia
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19. Bone marrow biopsy: 70% cellularity, increased
atypical plasma cells ( Grape cells, Mott cells)
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20. Staging System for MM
Durie – Salmon
Stage I
Stage II
Stage III
International staging system
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21. Medical Management
Melphalan and Prednisone
Bisphosphonate therapy
Corticosteroids
VAD (Vincristine , Doxorubicine(adiramycin)
Dexamethasone)
Thalidomide
Interferon- alpha
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22. Treatment of Multiple Myeloma
Patients < 65 - 70 years
 high-dose therapy with autologous stem cell
transplantation
 non-myeloablative therapy with allogeneic
transplantation
 Radiation therapy (palliates localized pain)
 Surgical therapy (vertebral kyphoplasty- Baloon
expansion of bone )
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23. complications
Anemia
Renal insufficiency
Fractures, limitation of mobility, vertebral
compression
Graft –versus-host disease
Osteonecrosis of jaw (IV bisphosphonates)
Thrombocytopenia
Amyloidosis
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24. DENTAL MANAGEMENT
Pre operative considerations
Intra operative considerations
Post operative considerations
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25. Oral health care recommendations for pt with MM
receiving chemotherapy/ hemopoietic stem cell
transplantation
Oral hygiene recommendations for pts with MM
Drugs – Modified dosing intervals
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26. Thank you
H
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