Extramedullary Plasmacytomas of the Oral Cavity: A Case Report and Review of the Literature

Introduction: Multiple myeloma is a hematologic malignancy characterized by the proliferation of plasma cells and typically presents with lesions in bone, known as plasmacytomas. Through hematogenous spread, extramedullary plasmacytomas can develop in soft tissue in any location of the body. This case report describes a patient with multiple myeloma who presented with an extramedullary plasmacytoma on his maxillary gingiva and provides an updated review on the classification and characterization of extramedullary plasmacytomas of the oral cavity. Case description: A 53-year-old male with a known diagnosis of multiple myeloma was referred to our clinic for evaluation of a gingival nodule, which was tender to palpation and had been present for a month. Clinical examination revealed a 1.5 cm violaceous, red nodule of the maxillary buccal attached gingiva, which did not blanch on palpation. He had a similar 1 cm, smooth, red nodule of his cutaneous skin on his left arm. Radiographic examination with within normal limits without evidence of dental or bony pathology. An incisional biopsy revealed the diagnosis of plasmacytoma, indicating relapse and progression of the patient’s multiple myeloma. Practical implications: Multiple myeloma can present in the oral cavity either as intra-bony plasmacytomas, paraskeletal plasmacytomas, or extramedullary plasmacytomas in the soft tissue. Extramedullary disease representative of hematogenous spread is concerning for high-risk disease with a poor risk prognosis

Extensive Dental Caries in Patients with Oral Chronic Graft-versus-Host Disease

The oral cavity is one of the sites most frequently affected by chronic graft-versus-host disease (cGVHD) after allogeneic hematopoietic cell transplantation (alloHCT) and can be a significant source of patient morbidity due to both mucosal and salivary gland involvement. The development of dental decay is a potentially devastating oral complication that has only rarely been reported in the transplantation literature. The purpose of this study was to comprehensively characterize a cohort of patients with cGVHD who subsequently developed extensive dental caries. A retrospective case-record review was conducted for patients who had undergone alloHCT at Dana-Farber/Brigham and Women's Cancer Center between 1990 and 2010 and developed cGVHD-associated rampant dental decay. All patients underwent dental evaluation, involving soft and hard tissue examination and dental radiography, before and after alloHCT. Any dental caries diagnosed at the pre-alloHCT evaluation were treated definitively, such that all patients were considered free of caries at the time of admission for alloHCT. A total of 21 patients were identified, with a median time of cGVHD onset of 5.4 months (range, 2.2-18.5 months) after alloHCT. All patients were diagnosed with oral cGVHD, with 90% demonstrating mucosal involvement and 95% demonstrating salivary gland involvement. Post-alloHCT dental evaluation was performed at a median of 22 months (range, 4-81) after alloHCT, when 10 patients were diagnosed with gross caries and 8 patients had 4 or more affected teeth. Cervical and interproximal patterns of dental caries were frequently diagnosed. The proportions of patients with gross caries, one surface caries, and more than one surface caries (classified as 0, 1-3, and ≥4, respectively) were significantly higher after alloHCT than before alloHCT, with at least 50% of patients experiencing an increase. Patients with oral cGVHD who were free of caries at the time of transplantation developed extensive areas of cervical decay at a median of less than 2 years after alloHCT. This is the first comprehensive characterization of this severe late complication of alloHCT and oral cGVHD. Greater awareness by transplantation oncologists and dentists, as well as more aggressive preventive measures, are needed, as are further prospective studies to better elucidate the incidence of this complication, identify risk factors, and evaluate the effectiveness of preventive interventions

Development and feasibility of the misuse, abuse, and diversion drug event reporting system (MADDERS®)

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/134867/1/ajad12459.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/134867/2/ajad12459_am.pd

Factitial pemphigus-like lesions

The maxillofacial region is rarely subjected to self-inflicted conditions such as factitious disease. Nasal ulceration, facial emphysema, periorbital ecchymosis, mandibular subluxation, gingival and mucosal ulceration, dental and salivary gland pain and glossopharyngeal neuralgia have been reported as possible manifestations of factitious disease. We report a case of a young woman who presented with unilateral bullous and ulcerative oral and erythematous facial lesions that were initially diagnosed as pemphigus vulgaris but was later determined to be secondary to self-inflicted injuries. To the best of the authors? knowledge, this clinical scenario has not been previously reported in the context of a factitious disease and, therefore, may be considered in the differential diagnosis of oral vesiculobullous disorders

Guideline for the Prevention of Oral and Oropharyngeal Mucositis in Children Receiving Treatment for Cancer or Undergoing Haematopoietic Stem Cell Transplantation

PURPOSE: To develop an evidence-based clinical practice guideline for the prevention of oral mucositis in children (0-18 years) receiving treatment for cancer or undergoing haematopoietic stem cell transplantation (HSCT). METHODS: The Mucositis Prevention Guideline Development Group was interdisciplinary and included internationally recognised experts in paediatric mucositis. For the evidence review, we included randomised controlled trials (RCTs) conducted in either children or adults evaluating the following interventions selected according to prespecified criteria: cryotherapy, low level light therapy (LLLT) and keratinocyte growth factor (KGF). We also examined RCTs of any intervention conducted in children. For all systematic reviews, we synthesised the occurrence of severe oral mucositis. The Grades of Recommendation, Assessment, Development and Evaluation approach was used to describe quality of evidence and strength of recommendations. RESULTS: We suggest cryotherapy or LLLT may be offered to cooperative children receiving chemotherapy or HSCT conditioning with regimens associated with a high rate of mucositis. We also suggest KGF may be offered to children receiving HSCT conditioning with regimens associated with a high rate of severe mucositis. However, KGF use merits caution as there is a lack of efficacy and toxicity data in children, and a lack of long-term follow-up data in paediatric cancers. No other interventions were recommended for oral mucositis prevention in children. CONCLUSIONS: All three specific interventions evaluated in this clinical practice guideline were associated with a weak recommendation for use. There may be important organisational and cost barriers to the adoption of LLLT and KGF. Considerations for implementation and key research gaps are highlighted

Current practice of oral care for hematopoietic stem cell transplant patients: A survey of the eastern Mediterranean blood and marrow transplantation group

Introduction: The oral cavity is one of the most common sites impacted by hematopoietic stem cell transplantation (HSCT) with acute complications including mucositis, bleeding, salivary gland dysfunction, infection, and taste alteration. These complications may result in significant morbidity and can negatively impact outcomes such as length of stay and overall costs. As such, oral care during HSCT for prevention and management of oral toxicities is a standard component of transplant protocols at all centers. The objective of this study was to evaluate the current oral care practices for patients during HSCT at different transplant centers within the Eastern Mediterranean region.Material and methods: An internet-based survey was directed to 30 transplant centers in the Eastern Mediterranean region. The survey included five sections asking questions related to (1) transplant center demographics; (2) current oral care protocol used at the center and type of collaboration (if any) with a dental service; (3) use of standardized oral assessment tools and grading systems for mucositis; (4) consultations for management of oral complications; and (5) oral health needs at each center. Data are presented as averages and percentages.Results: A total of 16 responses from 11 countries were collected and analyzed, indicating a response rate of 53%. Eight centers reported that a dentist was part of the HSCT team, with four reporting oral medicine specialists specifically being part of the team. Almost all centers (15/16; 93%) had an affiliated dental service to facilitate pre-HSCT dental clearance with an established dental clearance protocol at 14 centers (87%). Dental extraction was associated with the highest concern for bleeding and the need for platelet transfusion. With respect to infection risk, antibiotic prophylaxis was considered in the setting of low neutrophil counts with restorative dentistry and extraction. All centers provide daily reinforcement of oral hygiene regimen. The most frequently used mouth oral rinses included sodium bicarbonate (68%) and chlorhexidine gluconate (62%), in addition to ice chips for dry mouth (62%). The most frequently used mucositis assessment tools were the World Health Organization scale (7/16; 43%) and visual analogue scale for pain (6/16; 37%). Mucositis pain was managed with lidocaine solution (68.8%), magic mouth wash (68.8%) and/or systemic pain medications (75%).Conclusions: Scope and implementation of oral care protocols prior to and during HSCT varied between transplant centers. The lack of a universal protocol may contribute to gaps in oral healthcare needs and management for this group of patients. Further dissemination of and education around available oral care guidelines is warranted.Clinical relevance: Considering oral care during HSCT a standard component of transplant protocols, the current study highlights the common oral care practices for patients at centers within the Eastern Mediterranean region

Immune checkpoint inhibitors in cancer therapy: Review of orofacial adverse events and role of the oral healthcare provider

Immune checkpoint inhibitors (ICIs) are a revolutionary class of antineoplastic therapy that restore anti-tumor immunity. Consequences of this enhanced immune response include a multitude of immune related adverse events (irAEs) that can affect any body system, including the mouth. Orofacial irAEs reproduce features of numerous immune-mediated conditions, including oral lichen planus, mucous membrane pemphigoid, and Sjögren syndrome, among others. The aim of this review is to summarize known orofacial irAEs and to familiarize oral healthcare providers with how to identify and manage these toxicities as part of the care team for patients treated with ICIs

3-D Radiative Transfer Calculations of Radiation Feedback from Massive Black Holes: Outflow of Mass from the Dusty "Torus"

Observational and theoretical arguments suggest that the momentum carried in mass outflows from AGN can reach several times L / c, corresponding to outflow rates of hundreds of solar masses per year. Radiation pressure on lines alone may not be sufficient to provide this momentum deposition, and the transfer of reprocessed IR radiation in dusty nuclear gas has been postulated to provide the extra enhancement. The efficacy of this mechanism, however, will be sensitive to multi-dimensional effects such as the tendency for the reprocessed radiation to preferentially escape along sight-lines of lower column density. We use Monte Carlo radiative transfer calculations to determine the radiation force on dusty gas residing within approximately 10 parsecs from an accreting super-massive black hole. We calculate the net rate of momentum deposition in the surrounding gas and estimate the mass-loss rate in the resulting outflow as a function of solid angle for different black hole luminosities, sightline-averaged column densities, clumping parameters, and opening angles of the dusty gas. We find that these dust-driven winds carry momentum fluxes of 1-5 times L / c and correspond to mass-loss rates of 10-100 solar masses per year for a 10^8 solar mass black hole radiating at or near its Eddington limit. These results help to explain the origin of high velocity molecular and atomic outflows in local ULIRGs, and can inform numerical simulations of galaxy evolution including AGN feedback.Comment: 15 pages, 14 figures. Submitted to ApJ; v2 Corrected spelling and other small typos; v3 Included additional details and references to match accepted versio

Editorial: Oral complications in cancer patients

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Clinical registry of dental outcomes in head and neck cancer patients (OraRad): rationale, methods, and recruitment considerations

Abstract Background Most head and neck (H&N) cancer patients receive high-dose external beam radiation therapy (RT), often in combination with surgery and/or chemotherapy. Unfortunately, high-dose RT has significant adverse effects on the oral and maxillofacial tissues, some of which persist for the life of the patient. However, dental management of these patients is based largely on individual and expert opinion, as few studies have followed patients prospectively to determine factors that predict adverse oral sequelae. In addition, many previous studies were conducted before wide-spread adoption of intensity-modulated radiation therapy (IMRT) and concurrent chemotherapy. The objective of this multi-center study is to systematically evaluate the oral health of subjects for 2 years after commencement of RT, with the goal of identifying risk factors that predict adverse oral outcomes post-RT. Methods This is a prospective multi-center longitudinal cohort study of H&N cancer patients who receive high-dose RT with curative intent. Planned enrollment is 756 subjects at 6 primary clinical sites (and their affiliated sites) in the USA. A baseline visit is conducted prior to the beginning of RT. Follow-up visits are conducted at 6, 12, 18 and 24 months from the start of RT. The primary outcome measure is the 2-year rate of tooth loss in patients who have received at least one session of external beam RT for H&N cancer. Secondary outcome measures include the incidence of exposed intraoral bone; incidence of post-extraction complications; change in Decayed Missing and Filled Surfaces (DMFS); change in periodontal measures; change in stimulated whole salivary flow rates; change in mouth opening; topical fluoride utilization; chronic oral mucositis incidence; changes in RT-specific quality of life measures; and change in oral pain scores. Discussion This study will contribute to a better understanding of the dental complications experienced by these patients. It will also enable identification of risk factors associated with adverse outcomes such as tooth loss and osteoradionecrosis. These findings will support the development of evidence-based guidelines and inform the planning of future interventional studies, with the goal of advancing improvements in patient care and outcomes. Trial registration ClinicalTrials.gov Identifier NCT02057510 , registered 5 February 2014