Multiple myeloma presenting as mandibular pain

Multiple myeloma (MM) is a systemic malignancy of plasma cells defined by monoclonal production of circulating immunoglobulins. Bone pain is a presenting feature in the majority of cases. Treatment may involve intravenous use of bisphosphonates, chemotherapy or haematopoietic stem cell transplantation. Here, we illustrate a first presentation of MM in a patient with mandibular pain and discuss radiographic, diagnostic and treatment challenges of orofacial issues in patients with MM.

A 69-year-old lady presented to an emergency oral surgery clinic with a month-long history of unilateral left-sided pain in her jaw. Examination revealed a buccolingual swelling of 2cm diameter in the lower left premolar region. Radiographic images demonstrated a 2cm lytic lesion in her mandible corresponding with the symptomatic region. Aspiration of the lesion was performed and histological analysis indicated an abundance of atypical plasma cells. Subsequent biopsy revealed sheets of plasmacytoid cells suggesting evidence of a plasmacytoma. Skeletal survey, bone marrow biopsy and serum analysis confirmed the presence of MM.

MM, although a systemic malignancy, can present via a variety of orofacial manifestations. The presence of a lytic lesion on plain radiographs should alert the dental practitioner to the possibility of the diagnosis. Treatment of orofacial bone pain may respond to intravenous bisphosphonates but care must be taken to avoid osteonecrosis of the jaw.

This case is an important reminder of the potential oral presentations of MM and underlines the importance of radiographic evaluation in patients with atypical symptoms and presentations.