MALIGNANT NEOPLASMS

Lymphoma

Intraoral lymphomas are infrequent in the general population but are the second most frequent malignant neoplasia found in AIDS patients. The vast majority of AIDS associated lymphomas are extremely aggressive B cell lymphomas which are non Hodgkin's lymphoma (NHL). These lymphomas are extranodal and in AIDS patients about 5% of extranodal NHL are intraoral. It has been estimated than almost 100% of the AIDS associated NHL contain Epstein-Barr virus. NHL develops as a fast growing mass generally on the gingiva, palate or tongue and soon it ulcerates and undergoes extensive necrosis. Pain may not be present in the initial stages of the tumor. Clinically the mass may be erythematous or purplish in color with a boggy consistency. Some cases may develop in a pre-existing periodontal disease such as necrotizing ulcerative periodontitis. Therefore, it is imperative that in those cases where the treatment of the periodontal disease is not effective, a biopsy be performed to rule out the possibility of an associated NHL. The survival rate for AIDS patients with oral NHL has been estimated at an average of 8 months.

After the diagnosis is confirmed by biopsy the treatment is in the hands of the oncologist and consists of multi-drug chemotherapy and radiation. The dentist's participation in the management of these patients is to maintain an acceptable level of intraoral health. Rinses with chlorhexidine gluconate should be prescribed as antimicrobial prior to radiation therapy to ameliorate glossitis and mucositis which are a consequence of radiation. In case of xerostomia, also as a consequence of the treatment, saliva substitutes should be prescribed.

Figure 30. This 39 year-old man presented a generalized puffy erythema confined to the maxillary gingiva. A biopsy confirmed the diagnosis of non Hodgkin lymphoma. Blood studies did not reveal changes compatible with leukemia. A bone marrow study was ordered but the patient did not comply with the appointment and was lost to follow-up.

Other malignancies.

Similar to the benign neoplasms, malignant ones can arise de-novo in the gingiva. Malignant tumors, besides the ones already presented here, are extremely rare in the gingiva. Any rapid growth, especially if it is painful, should arise the suspicion of a malignant process. Careful clinical evaluation, including cervical lymph nodes palpation, radiographs to determine possible bone involvement, consultation with other specialists and a biopsy, are the indicated procedures to arrive at a final diagnosis.