Multiple myeloma is a cancer of plasma cells, a type of white blood cell in the bone marrow that is part of the immune system. When these cells grow uncontrollably, they can impact the bones, creating a direct link to oral health. The treatments used to manage multiple myeloma can also affect the mouth and jaw, making specialized dental care an important part of a patient’s overall plan.
Oral Health Effects of Multiple Myeloma Itself
Multiple myeloma can manifest in the oral cavity and facial structures. The disease accelerates the breakdown of old bone tissue faster than new bone can be formed to replace it, leading to osteolytic lesions, which are weakened or “punched out” areas. When these lesions develop in the jawbone, they can cause persistent pain, localized swelling, or loose teeth.
In up to 30 percent of cases, multiple myeloma directly affects the bones of the face and mouth, resulting in symptoms from a dull ache to sudden fractures. Nerve damage within the jaw is another potential consequence, causing numbness or a tingling sensation in the chin and lower lip, known as “numb chin syndrome.” This is a notable neurologic symptom of the disease.
Multiple myeloma can also impact soft tissues. Cancerous plasma cells may form tumors on the gums (gingival masses), which can be an initial sign of the disease. Low blood platelet counts can lead to gums that bleed easily. In some cases, an abnormal protein produced by the disease can cause an enlarged tongue, a condition known as macroglossia.
Dental Side Effects of Cancer Therapies
Treatments for multiple myeloma can produce side effects that affect oral health. Chemotherapy attacks rapidly dividing cells, including the healthy cells lining the mouth, which can lead to oral mucositis. This condition involves painful inflammation and sores that make eating, drinking, and speaking difficult.
Xerostomia, or dry mouth, is another frequent complication of cancer therapy. Certain treatments reduce saliva production, which normally protects the mouth. A persistent dry mouth increases the risk for cavities because saliva is not available to wash away food and neutralize acids. It can also make swallowing difficult and alter the sense of taste.
Myeloma and its treatments often suppress the immune system. A weakened immune state makes a person more vulnerable to oral infections. This increases the risk of developing fungal infections like oral thrush (candidiasis) or viral infections like the herpes simplex virus, which causes cold sores.
Understanding Medication-Related Osteonecrosis of the Jaw
A concern in the dental management of multiple myeloma is Medication-Related Osteonecrosis of the Jaw (MRONJ). This is a serious but uncommon side effect where an area of the jawbone fails to heal, becomes exposed through the gums, and begins to die. The condition can cause pain, swelling, and infection, with the primary symptom being visible, exposed bone in the mouth that persists for weeks.
The risk of MRONJ is strongly associated with bone-modifying agents used to slow bone damage from myeloma. This category includes bisphosphonates, like zoledronic acid (Zometa), and the RANKL inhibitor denosumab (Xgeva). These drugs interfere with osteoclasts, the cells that break down old bone, which slows bone destruction but also impedes the jaw’s ability to heal.
Several factors influence the likelihood of developing MRONJ. Intravenous medications carry a higher association than oral forms, and longer-term use of these agents increases the risk. The primary trigger for MRONJ is invasive dental surgery, such as tooth extractions or dental implant placement. These procedures create a wound that may not heal properly in patients on these therapies.
Guidelines for Dental Care
Dental management for a person with multiple myeloma requires careful planning between the patient, oncologist, and dentist. Before myeloma treatment begins, a thorough dental examination with X-rays is recommended to identify pre-existing problems like cavities or infections. Addressing these issues beforehand can prevent the need for invasive procedures when risks are higher.
Once myeloma therapy is underway, dental care focuses on prevention and maintenance. This includes meticulous oral hygiene with a soft-bristled toothbrush to avoid irritating sensitive gums. It is also important to manage dry mouth by staying hydrated, using saliva substitutes, or chewing sugar-free gum. Regular dental check-ups for professional cleanings and monitoring should continue, as they are a safe way to maintain oral health.
When dental procedures are necessary, a collaborative approach is needed. Routine, non-invasive work like fillings can be performed safely. For any invasive procedure, like a tooth extraction, the dental and oncology teams must work together. They will assess the benefits against the risk of developing MRONJ to ensure the work is performed as safely as possible.