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Dental Issues and Multiple Myeloma

Posted on October 11, 2021
Medically reviewed by
Mark Levin, M.D.
Article written by
Jennifer Shuman

Recent medical advances have helped improve the survival rates and quality of life for people living with multiple myeloma. This condition sometimes causes dental problems, but regular visits to the dentist in coordination with an oncologist can help reduce instances of serious oral health issues.

Myeloma-associated bone disease is caused by the loss of bone calcium and bone strength. Bone is naturally remodeled over a person’s lifetime. Osteoclasts are cells that absorb and degrade bone tissue. Osteoblasts are cells that create new bone tissue. This process is normally well balanced — destruction and creation leave the bone in the same overall state. In people who have multiple myeloma, however, the osteoclasts can degrade bone faster than the osteoblasts can replace it. This can lead to the breakdown and softening of bone tissue in any part of the body, including the jaw and teeth.

Osteolytic lesions (areas of severe bone loss) are found in 70 percent to 80 percent of people diagnosed with multiple myeloma. The incidence of bone degradation continues to rise over the course of the disease. Weakened bones can lead to several problems, including dental issues. For some people with multiple myeloma, their disease directly causes oral problems such as:

  • Gingival masses — Tumors on the gums
  • Osteonecrosis of the jaw (ONJ) — Sores in the soft tissues of the mouth that leave bone exposed
  • Maxillofacial bone pain — Pain in the jaw

Treatments for multiple myeloma can also cause dental issues. One MyMyelomaTeam member shared, “My current meds don’t cause too many issues … My teeth and gums have become more problematic since my meds cause a dry mouth. I have to get a super cleaning at the dentist soon!”

Risk Factors for Dental Problems

People with multiple myeloma are already at an increased risk of developing dental issues. Other factors, such as age, myeloma treatment type, and frequency of dental cleanings can make dental problems more or less likely.

Age

Multiple myeloma is more common in older adults. These individuals are at a higher risk of developing treatment-related side effects, and they are more likely to have other complicating conditions. In addition, older adults are more likely to have dental disease unrelated to multiple myeloma treatment.

Treatment

Certain types of cancer treatments can increase the risk of developing dental problems. All existing dental issues should be fixed before starting bisphosphonate therapies. Bisphosphonates are often used to treat bone damage and systemic hypercalcemia (high levels of calcium in the blood) caused by multiple myeloma. The medicines inhibit the osteoclasts, slowing down the process of bone loss. Zoledronic acid and pamidronate are two of the most common drugs used in this treatment.

Dental exams before bisphosphonate therapy can reveal problems that need surgical or invasive dental treatment. Although bisphosphonates are effective at preventing bone damage, they can also cause problems with bone healing in a small subset of people. This is especially problematic after dental surgery, which is why it’s recommended to have all dental work completed before starting the treatment.

During bisphosphonate treatment, an oncologist and dentist should check your oral health at least once a year. Avoid invasive procedures, such as having a tooth removed, getting an implant, or undergoing jaw surgery, if possible: They can cause unintended teeth or jawbone death. If you require invasive procedures, you should pause bisphosphonate therapy for 30 to 90 days before and after the invasive procedure. Less invasive dental procedures, such as cleanings, cavity fillings, and crowns can be done during bisphosphonate treatment.

Osteonecrosis of the Jaw

ONJ is an uncommon but serious potential side effect of bisphosphonate treatment. It is defined as jaw lesions (exposed oral bones) that do not heal within six to eight weeks of appropriate treatment.

Risk Factors

Risks factors for ONJ include:

  • Invasive dental procedures or surgeries
  • Dental implants
  • Intravenous bisphosphonate treatment
  • Longer time of bisphosphonate treatment
  • Use of corticosteroids
  • Multiple myeloma

One study reported that participants who developed ONJ were diagnosed about 14 months from the start of treatment.

Treatments to prevent bone fractures in myeloma are important. Unfortunately, they can also cause bone complications. Between 4 percent and 11 percent of people who undergo bisphosphonate treatment report episodes of ONJ. This condition has also been found in patients taking Xgeva (denosumab). The risk of developing ONJ increases with the dose and time of bisphosphonate treatment. One study reported that the use of bisphosphonates for one year results in ONJ in about 1.5 percent of people, whereas use for three years causes ONJ in about 7.7 percent of people. The development of ONJ is more common in people undergoing bisphosphonate zoledronic acid injections.

The risk of developing ONJ is higher after an invasive dental procedure. Taking a course of preventive antibiotics before dental procedures significantly lowers the risk of developing ONJ. Due to the risks, some oncologists or dentists may decide not to perform dental surgery during multiple myeloma treatment, if possible.

One MyMyelomaTeam member shared their experience with dental procedures: “Since my diagnosis, my teeth keep breaking off. I have had several root canals done, and then they grind the teeth down to the gumline. The cancer dentist said not to have teeth pulled unless it’s unavoidable. They are afraid that the socket might not heal, and I could get a jaw infection from it.”

Symptoms of Osteonecrosis

The first sign of ONJ is an exposed jawbone. Other symptoms include:

  • Swelling of the gums
  • Loose teeth
  • Drainage from areas in the oral cavity that won’t heal
  • Numbness or heaviness in the mouth and jaw
  • Mouth infections

These symptoms can affect the mandible (lower jaw) and the maxilla (upper jaw).

Management and Treatment

ONJ is a complicated disease. Treatments are still being studied and developed. Current treatments for ONJ may include surgery or medications. Depending on its location, ONJ may be best treated with surgery. This usually involves pulling a nearby flap of tissue over the exposed bone to cover it.

According to a meta-analysis of available studies, the timeline of surgery (whether it occurred soon after diagnosis or was delayed) did not seem to affect the healing of ONJ. The same study reported that temporarily pausing bisphosphonate or denosumab treatment around the time of invasive dental procedures may help ONJ heal.

One study in mice looked at the differences in ONJ healing with bisphosphonate and denosumab treatments. They reported that ONJ healed better in mice treated with denosumab compared to mice treated with bisphosphonates.

Regular Preventive Dental Care Is the Best Treatment

Preventive dental care, including regular and thorough dental hygiene, routine oral exams, teeth cleanings, and X-rays, helps decrease the risk of developing severe dental problems. Oncologists and dentists should partner together to educate people living with multiple myeloma about the best oral hygiene practices for their specific situation.

One MyMyelomaTeam member shared, “Make sure you get regular dental visits. I developed osteonecrosis, and it was diagnosed on a routine dental exam.”

Your dentist and oncologist should communicate with you (and each other) about dental checkups and any dental procedures you might need. Most dentists do not regularly see people with multiple myeloma, and they may be unaware of the potential complications of the malignancy or its treatments.

One MyMyelomaTeam member suggested, “I believe it is critical for your general health care to build a relationship of mutual trust with your physicians, nurses, and all other medical and general support staff who are involved in your care. Also, from personal experience, if you have other ongoing issues, make sure to keep all of your physicians aware of their current state.”

Thorough and frequent dental cleanings and exams can lower the risk of developing severe dental problems and ONJ. After posting about their dental issues, one MyMyelomaTeam member shared, “Thanks for your insights … I am realizing I have to be really good about dental care now.”

Talk With Others Who Understand

MyMyelomaTeam is the social network for people living with multiple myeloma and their loved ones. On MyMyelomaTeam, more than 12,000 members come together to ask questions, give advice, and share their stories with others who understand life with multiple myeloma.

Are you living with multiple myeloma? What has your dental health experience been like? Share your experience in the comments below, or start a conversation by posting on your Activities page.

All updates must be accompanied by text or a picture.
Mark Levin, M.D. is a hematology and oncology specialist with over 37 years of experience in internal medicine. Review provided by VeriMed Healthcare Network. Learn more about him here.
Jennifer Shuman is a graduate student at Vanderbilt University pursuing her Ph.D. in pathology, microbiology, and immunology. Learn more about her here.

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