multiple myeloma is a monoclonal malignant neoplasm of plasma cell origin which occurs in the bone marrow and may result in extensive destruction of skeletal structures .
it most commonly affects the skull , vertebrae , and pelvis , with pain , fatigue , swelling , and anemia being some of the most common clinical presentations .
an 83-year - old african american female presented to the emergency department with mild pain and swelling over the posterior left mandibular alveolar ridge [ figure 1 ] .
the lesion was approximately 2 cm  2 cm  1.5 cm in the area of the missing first molar .
on palpation , it was firm with no fluctuance . radiographically , an ill - defined radiolucency of the alveolar bone was identified [ figure 2 ]
. initial clinical presentation of the patient with gingival swelling between teeth 18 and 20 radiograph showing an ill - defined radiolucent area in the bone between teeth 18 and 20 an incisional biopsy revealed a malignant neoplasm of hematopoietic origin with sheets of malignant plasma cells ranging from mature to immature forms as well as pleomorphic - cells and occasional binucleated cells [ figure 3 ] .
the neoplastic plasma cells were strongly positive with kappa light chain antibody and with cd138 [ figure 4 ] , both supporting the histological diagnosis of plasmacytoma .
( a ) low magnification shows stratified squamous mucosa on right upper end with cellular infiltrate in left lower portion of the image ; ( b ) magnification of h and e histology shows sheets of plasma cells , most are large and atypical with large nuclei and prominent nucleoli immunohistochemistry stain for cd138 antibody .
note uniform positive staining with cd138 , a marker for plasma cells a bone marrow aspirate biopsy was performed on the left posterior iliac crest where sheets of neoplastic plasma cells were identified .
a random urine collection showed elevated bence - jones protein ( 0.09 g ) and a subsequent 24 h urine collection demonstrated a level of 0.13 g ( normal 0.0500.080 ) .
the disease is usually found in the sixth and seventh decades of life with a median age of 62 , 66 , 71 .
it is a multicentric and generalized bone marrow disease that affects multiple bones and can include the jaws . in a review of 193 patients with diagnosed multiple myeloma ,
epstein et al . reported that out of 783 multiple myeloma patients , 14.1% had oral manifestations in the form of jaw pain , severe periodontitis , tooth mobility , bone destruction , pathologic fracture , paresthesia , and soft tissue swelling .
usually , if the jaws are involved , it is an indication of an advanced stage of the disease . in the case
we report , no other lesions were identified on the osseous skeletal survey performed the same month as the biopsy .
this patient had a systemic manifestation of multiple myeloma despite the jaw being the only bone affected ; she had mild anemia , elevated serum calcium , and bence - jones protein in her urine .
she also had sheets of neoplastic plasma cells in her bone marrow biopsy performed on the left posterior iliac crest .
the neoplastic plasma cells were positive with cd138 antibody confirming the presence of the disease in an area away from the jaw .
we present a case of multiple myeloma first manifesting in the mouth as a mildly painful gingival swelling with underlying irregular bone destruction .
we recommended that all patients receive a routine oral examination by their dentist and primary care physician to insure early recognition of malignant neoplasms of the mouth .
 it is rare that multiple myeloma ( mm ) occurs as a primary lesion in the jaws ; we report such a case in an elderly patient involving the gingiva of the left posterior mandible . 
 multiple myeloma is a monoclonal malignant neoplasm of plasma cell origin which occurs in the bone marrow and may result in extensive destruction of skeletal structures . 
 if the jaws are involved , it usually indicates an advanced stage of the disease.thi s makes our case very unique due to the fact no other osteolytic lesions were identified at the time of the diagnosis of multiple myeloma . 
 we report a rare case of multiple myeloma which was diagnosed from an intraoral gingival lesion on the lower left mandible . 
INTRODUCTION
CASE REPORT
DISCUSSION