Multiple myeloma masquerading as mandibular medication-related osteonecrosis of the jaw: a case report.

This is a unique case report of a 67-year-old female diagnosed with multiple myeloma and extensive use of intravenous bisphosphonate, whose clinical and radiographic presentation of an oral lesion made it challenging to confirm its definitive diagnosis. This patient was referred to the dental service for a suspected medication-related osteonecrosis of the jaw (MRONJ). Clinically, the lesion was located underneath a fixed partial denture in the left posterior mandible. There was a purulent swelling on the lingual side of the fixed partial denture, and a hyperplastic exophytic lesion on the buccal side of the bridge. Panoramic radiograph showed a well circumscribed radiolucent lesion in the left mandible. A biopsy of the gingival lesion on the buccal aspect was inconclusive. As the positron emission tomography scan showed lytic lesions, oral manifestation of multiple myeloma could not be ruled out. A computed tomography-guided biopsy of the left mandible showed plasma cell neoplasm in the histological analysis. Upon confirmed diagnosis, the patient was treated with 20Gy to the left mandible and subsequent debridement of the loose necrotic bone. Following treatment, this gingival lesion resolved completely, and the tumour has remained stable till date.

Dental intervention for the irradiated patient: time to re-evaluate dental treatment algorithms?

Modern radiotherapy delivery systems and treatment strategies are aimed at limiting the irradiation of healthy structures in the head and neck. This seeks to mitigate post-treatment toxicities and complications such as osteoradionecrosis of the jaw. Given the changes to radiotherapy, conventional workflows for the management of patients requiring dentoalveolar surgery may no longer be suitable. It may therefore be appropriate to revisit current treatment algorithms for the management of patients with radiotherapy to the jaws who require dentoalveolar surgery. At present, there are poor data on this. Development of a randomised trial may be warranted to establish the true relative risk for extraction of teeth in the setting of modern radiation therapy delivery systems.

Molecular profiling of oral microbiota in jawbone samples of bisphosphonate-related osteonecrosis of the jaw.

OBJECTIVE: Infection has been hypothesized as a contributing factor to bisphosphonate (BP)-related osteonecrosis of the jaw (BRONJ). The objective of this study was to determine the bacterial colonization of jawbone and identify the bacterial phylotypes associated with BRONJ. MATERIALS AND METHODS: Culture-independent 16S rRNA gene-based molecular techniques were used to determine and compare the total bacterial diversity in bone samples collected from 12 patients with cancer (six, BRONJ with history of BP; six, controls without BRONJ, no history of BP but have infection). RESULTS: Denaturing gradient gel electrophoresis profile and Dice coefficient displayed a statistically significant clustering of profiles, indicating different bacterial population in BRONJ subjects and control. The top three genera ranked among the BRONJ group were Streptococcus (29%), Eubacterium (9%), and Pseudoramibacter (8%), while in the control group were Parvimonas (17%), Streptococcus (15%), and Fusobacterium (15%). H&E sections of BRONJ bone revealed layers of bacteria along the surfaces and often are packed into the scalloped edges of the bone. CONCLUSION: This study using limited sample size indicated that the jawbone associated with BRONJ was heavily colonized by specific oral bacteria and there were apparent differences between the microbiota of BRONJ and controls.

Sequelae and complications related to dental extractions in patients with hematologic malignancies and the impact on medical outcome.

OBJECTIVE: The purpose of this retrospective study was to evaluate sequelae and complications after dental extractions and to analyze their impact on medical treatment in patients with myelodysplastic syndrome, acute and chronic leukemia, and multiple myeloma during a 3-year period. STUDY DESIGN: The study population included 388 patients with hematologic malignancies. All medical and dental charts were reviewed in a retrospective fashion to identify patients who received dental extractions. Preexisting dental disease and intervention (extraction) were evaluated, and parameters such as days of hospitalization and survival rate were compared with those of the remainder population who did not receive dental extractions. RESULTS: Of the 388 patients, 69 underwent dental extractions and 9 had sequelae and complications after the intervention. The resulting complication rate of 13% was reported. Although some patients did experience delay of chemotherapy or bone marrow transplant (BMT), or both, no significant difference was found in the number of days in the hospital for BMT and the survival rate for the patients with sequelae and complications (n = 9) and for the remainder population (n = 319) ( >.05). CONCLUSION: Dental extraction intervention provided in the prechemotherapy and pre-BMT time frame did not have a negative bearing on medical outcome.

Unusual gingival presentation of post-transplantation lymphoproliferative disorder: a case report and review of the literature.

Post-transplantation lymphoproliferative disorder is a well-documented complication of solid organ or bone marrow transplantation. Histologically, it is characterized by an abnormal proliferation of lymphocytes, which can range from benign B-cell hyperplasia to malignant lymphoma. Non-Hodgkin's lymphoma (NHL) is associated with several risk factors, such as congenital or acquired immunodeficiency states, autoimmune disorders, and infectious agents (eg, Epstein-Barr virus). Primary sites of presentation in the head and neck are Waldeyer's ring, paranasal sinuses, salivary glands, the oral cavity, and the larynx. Clinical appearance of gingival NHL varies but is usually found to be an asymptomatic gingival enlargement or mass resembling a pyogenic granuloma. We present a patient with a gingival ulceration that was subsequently diagnosed as Epstein-Barr virus malignant lymphoma resulting from the immunosuppression needed to prevent graft-versus-host disease after bone marrow transplantation.

Resection and immediate microvascular reconstruction in the management of osteoradionecrosis of the mandible.

BACKGROUND: Management of osteoradionecrosis (ORN) remains a difficult and challenging problem. The traditional approach using debridement, antibiotics, and occasionally hyperbaric oxygen is usually successful in treating minimal ORN. However, when bone and soft-tissue necrosis is extensive, the conservative approach usually requires intensive care over a long period of time and often yields unsatisfactory functional and cosmetic results. METHODS: Within the past 5 years, we have used radical resection of the mandible with immediate microvascular reconstruction in the treatment of extensive ORN of the mandible. This aggressive surgical approach was used in six patients with advanced ORN of the mandible, all of whom had failed initial conservative treatment, including hyperbaric oxygen therapy in three. A fibular free graft with microvascular anastomosis was used in all patients. RESULTS: All the patients healed primarily with minimal postoperative morbidity and excellent cosmetic results. Two patients subsequently required removal of some of their hardware. One patient had placement of osseointegrated implants with an excellent cosmetic and functional result. CONCLUSION: Microvascular reconstruction with its own blood supply seems to expedite bone healing and limit further osteoradionecrosis of the remaining mandible. Although prevention is the primary goal in radiation injury, our experience suggests that radical resection with free microvascular reconstruction offers significant advantages to selected patients with extensive ORN of the mandible.

Quality of life of maxillectomy patients using an obturator prosthesis.

BACKGROUND: The psychosocial adaptation of patients who had undergone a resection of the maxilla for cancer of the maxillary antrum and/or hard palate with the placement of an obturator prosthesis to restore speech and eating function was studied. METHODS: Forty-seven patients were interviewed who had a maxillectomy with an obturator prosthesis at Memorial Sloan-Kettering Cancer Center, an average of 5.2 years (SD = 2.4 years) ago, 94% of whom had some of their soft palate resected. Interviews were conducted by telephone by a trained research interviewer, using a series of questionnaires to assess their satisfaction with the functioning of their obturator, and the psychological, vocational, family, social, and sexual adjustment. Measures included the Obturator Functioning Scale (OFS). Psychosocial Adjustment to Illness Scale (PAIS), Mental Health Inventory (MHI), Impact of Event Scale, and Family Functioning Scale. RESULTS: Using multiple regression and discriminant function analyses, satisfactory functioning of the obturator prosthesis, as measured by the OFS, was found to be (1) the most highly significant predictor of adjustment, as measured by the PAIS (p < .0001) and the MHI Global Psychological Distress Subscale (MHI-GPD) (p < .001), and (2) significantly related to their perception of the negative socioeconomic impact of cancer upon their lives. The most significant predictor of better obturator functioning were the extent of resection of their soft palate (one third or less, p < .001), and hard palate (one fourth or less, p < .01). Specific aspects of obturator functioning that most significantly correlated with better adjustment (PAIS, MHI-GPD) were: less difficulty in pronouncing words (r = .40 and r = .51, respectively, p < .01), chewing and swallowing food (r = .27-.46, p < .05), and less change in their voice quality after surgery (r = .52 and r = .56, respectively, p < .001). CONCLUSIONS: These findings suggest that a well-functioning obturator significantly contributes to improving the quality of life of maxillectomy patients.

Osseointegrated implants in microvascular fibula free flap reconstructed mandibles.

In the past, prosthodontic rehabilitation of patients who underwent segmental mandibular resection relied on removable prostheses, which were less than ideal. The advent of the microvascular free flap has provided improved appearance and function through reconstruction of the skeletal integrity of the mandible. In select patients osseointegrated implants strategically placed in the reconstructed mandible can be used to restore masticatory function. Patient selection criteria and techniques are discussed.

Orbital prosthesis with a magnetically retained ocular component supported by osseointegrated implants.

Positioning of the ocular component within an orbital prosthesis must simulate conversational gaze. Using osseointegrated implants and an associated superstructure, a fixed reference point can be established for positioning an ocular prosthesis. This method can simplify the laboratory procedure and obviate the need for ocular component repositioning in replacement prostheses. This article describes the fabrication of an orbital prosthesis with a magnetically retained ocular section supported by osseointegrated implants.

Osseointegrated implants and functional prosthetic rehabilitation in microvascular fibula free flap reconstructed mandibles.

The mandibulectomy deformity can be alleviated by immediate mandibular reconstruction using the microvascular fibula free flap. Before the advent of microvascular reconstruction, conventional and maxillofacial prosthetic rehabilitation offered limited success after surgery due to the failure to reestablish the bony foundation and soft tissues (tongue, floor of mouth, vestibule) anatomically and physiologically. With proper multidisciplinary pretreatment planning and postoperative treatment, osseointegrated implants can be strategically placed in patients with these reconstructed mandibles to restore occlusal and masticatory function. The records of seven patients who underwent reconstructive surgery and osseointegrated implants were reviewed, with an emphasis on the variety of prosthetic designs and principles used to maximize long-term efficiency and preservation of tissues.

The maxillary immediate surgical obturator prosthesis.

The use of the maxillary immediate surgical obturator prosthesis has become the standard of care for patients undergoing maxillectomies at Memorial Sloan-Kettering Cancer Center. A protocol of treatment is described that includes preoperative, operative, and postoperative guidelines that have yielded predictably successful results. The objectives of such treatment include support and protection for the surgical dressing, improvement of speech and deglutition, and a psychologic boost for the patient's self-image.

Periodontal disease as a function of life events stress.

Studies relating stress and oral pathology have been limited to animal experiments or clinical studies of personality and psychological health that have ignored the role of specific life events. The present study related measurements of life events stress to measurements of periodontal disease. Subjects were fifty male volunteers recruited from a pool of dental patients from the Brooklyn VA Outpatient Dental Clinic. Oral examinations were given to determine the degree of periodontitis and gingivitis. Evidence of other somatic symptomatology was assessed by the somatization subscale of the Brief Symptom Inventory. The degree of life events stress was assessed with the Life Experience Survey. Measurements of life events stress were found to be significantly correlated with measures of periodontal disease. Periodontal disease was more severe and widespread as stressors increased. Subjects were found whose general physical health was unrelated to their life situation.