multiple myeloma is a malignant neoplasm that is characterized by a monoclonal proliferation of plasma cells .
the clinical manifestations of the disease occur as a result of an expanding plasma cell mass in the bone marrow and other factors produced by these cells such as monoclonal immunoglobulin , bence - jones proteins and osteoclast activating factors .
the common clinical signs and symptoms of multiple myeloma include pain in the bone , fatigue , anemia and infectious diseases .
oral and maxillofacial manifestations as an initial sign or symptom of multiple myeloma are rare . in 12 - 15% of cases ,
oral involvement can be apparent as swelling , orofacial pain , mobility of teeth , numbness and paresthesia , hemorrhage , fracture and root resorption .
we hereby present a case of multiple myeloma with first clinical manifestation as generalized gingival enlargement .
a 58-year - old male patient was referred to our department because of the generalized enlargement of gingiva .
the enlargement was first noted by the patient 6 months prior to the referral , and progressed steadily since then .
the intraoral examination revealed soft , granular , friable , non - tender , and red / magenta enlargement that bled spontaneously .
the enlargements were present on both buccal and lingual / palatal sides [ figure 1 ] . on physical examination , grade iii mobility was observed in 16 , 17 , 18 , 36 , 37 .
the medical history of the patient included epilepsy for which he took prescribed medication with no occurrence of seizure for last 10 years . based on clinical presentation , a provisional diagnosis of inflammatory gingival enlargement
routine blood investigations were done along with hiv and hepatitis b and sputum examination to rule out any leukemic infiltration and enlargement associated with tuberculosis .
orthopantomography was advised , which revealed severe bone loss in 16 , 17 , 18 and 36 , 37 regions .
after phase i therapy and consultation with the physician , gingivectomy was performed in anterior mandibular region and excised tissue was sent for histopathological examination .
the patient was followed up every week [ figure 2 ] but after 1 month the clinical examination revealed recurrence of enlargement in the anterior mandibular region [ figure 3 ] .
the subepithelial zone showed infiltration by sheets of plasma cells mainly mature with few being less differentiated [ figure 4 ] .
based on these findings , serum protein electrophoresis and urine analysis for bence - jones proteins was carried out .
subsequently , patient was advised to undergo cranial and pelvic radiography [ figures 6 and 7 ] .
the patient was diagnosed as a case of multiple myeloma and chemotherapy was started with thalidomide .
gingiva 10 days after excisional biopsy was taken recurrence after 1 month of biopsy areas of ulceration and sheets of plasma cells multinucleate and binucleate plasma cells pelvic radiograph showing osteolytic lesions skull radiograph showing osteolytic lesions normal gingiva 1 month after chemotherapy
multiple myeloma is the most aggressive plasma cell neoplasia and most common primary malignancy of bone .
it has a predilection for areas of active hematopoiesis such as the lumbar spine , ribs , and pelvic bones .
jawbone involvement in multiple myeloma is common and often occurs in the advanced stages of the disease .
jaw involvement in multiple myeloma was reported by bruce and royer to have a prevalence rate of 28.8% ( 17 of 59 total cases ) .
epstein et al . , reported that 14.1% of 783 multiple myeloma cases had oral manifestations .
lesions such as swelling , orofacial pain , mobility of teeth , numbness and paresthesia , hemorrhage , fracture and root resorption are more frequently found in the mandible than in the maxilla , especially in the posterior third and angle of the jaw , perhaps because of greater hematopoietic activity in these areas . a radiographic survey of patients with multiple myeloma reveals multiple well - defined  punched out  radiolucencies involving bone .
these radiolucent areas of bone contain the abnormal plasma cell proliferations that characterize the disease . in our case ,
type 2 bone involvement was seen , which is by far , the most common presentation of multiple myeloma . in conclusion ,
dental surgeons can play an important role in the early recognition of oral lesions with underlying systemic disease , thus preventing the morbidity and mortality associated with such pathologies .
 multiple myeloma is a malignant neoplasm that is characterized by a monoclonal proliferation of plasma cells . 
 oral and maxillofacial manifestations as an initial sign or symptom of multiple myeloma are rare . a 58-year - old male patient presented with generalized gingival enlargement for last 6 months . based on clinical presentation , 
 a diagnosis of gingival hyperplasia was made . 
 after phase i therapy , excisional biopsy was taken in anterior mandibular region and excised tissue was sent for histopathological examination . 
 the histopathology report revealed a lining of stratified squamous epithelium with foci of ulceration . 
 the subepithelial zone showed infiltration by sheets of mainly binucleate and multinucleate plasma cells , few cells being less differentiated . 
 rounded cytoplasmic inclusion bodies were identified in many of these cells . after a series of clinical investigations , a case of  multiple myeloma  was diagnosed . 
 patient presenting with generalized gingival hyperplasia should be worked up for systemic disease like multiple myeloma . 