The de­ci­sions that we must make as cancer patients are all about risk versus reward. If we are told that, without a recommended treat­ment, we will surely die, then the choice is pretty easy, almost re­gard­less of the risk.

But the de­ci­sions that we face are rarely so easy.

Among patients and care­givers, the most hotly debated myeloma treat­ment de­ci­sion is whether or not to undergo a stem cell trans­plant. There are numerous articles on the topic, and the question is the subject of many discussion threads in the Beacon's forum ^[1]. At the end of the day, rea­son­able minds can differ.

One myeloma subject that was not controversial, at least to me, when I was starting with my myeloma treat­­ment was the use of bis­phos­phonates such as Zometa ^[2] (zoledronic acid) and Aredia ^[3] (pamidronate). It was presented to me by my oncologist as unquestionably the thing to do. Bisphos­phonate treat­ment is part of what we call “the standard of care,” as highlighted by its inclusion in several dif­fer­en­t treat­ment guidelines for newly diag­nosed multiple myeloma patients (see related Beacon ^[4] news article).

I was aware of the risk of devel­op­ing osteo­necrosis of the jaw (ONJ) from the use of bis­phos­phonates, but the poten­tial benefits seemed to be great, and the risk of ONJ very small.

As I wrote in my column back in May of last year ^[5], I did develop ONJ. I have seen pictures of, and read about, serious cases of ONJ. This can be a particularly gruesome affliction, producing mouth lesions that will not heal, and a jaw bone that appears to be coming apart. In my case, we caught it very early. All I had was a tiny piece of bone that came through the surface of my gum. Once the bone sliver came out, the gum healed quickly and com­pletely.

At that point, I felt that we had beaten the ONJ monster and my worries were over.

When I went to my oral surgeon last fall for a follow-up appoint­ment, I mentioned pain that I had been having in a tooth that had a root canal and a crown. The surgeon did x-rays and told me that there was sig­nif­i­cant in­fec­tion under the tooth and, because it was cracked below the gum line, it would have to come out. He be­lieved that, since my gum had healed so well after the piece of bone had come out, it would not be too risky to do the extraction. To aid the heal­ing, he would inject platelet-rich plasma into the gum.

At this point, I was under the impression that, if the extraction site healed as well as the site from which bone had come out, we would proceed to the next logical step – an implant. In fact, when I saw the oral surgeon two weeks post-extraction, I could have sworn that he said that, if it were not for my history of ONJ, he would schedule the implant procedure im­medi­ately, but in this case he wanted to wait another month to see how the heal­ing progressed.

When I went for the follow-up appoint­ment a month later, he examined the gum and pronounced the heal­ing to be “Perfect!” But what he said next was a com­plete surprise: He wanted our next appoint­ment be in one year!

When I asked about the implant, he said that, given my history and my use of in­tra­venous bis­phos­phonates for 18 months, he would not con­sider an implant under any cir­cum­stances.

I was speechless at first – which is saying some­thing, as I am rarely at a loss for words.

After regaining my voice, I pushed back, arguing that if an extraction was appro­pri­ate, an implant was not any riskier.

My oral surgeon is generally fairly aggressive. But, in this case, he was adamant. He would not do an im­plant.

Before having the extraction, I had familiarized myself with the American Association of Oral and Maxillofacial Surgeons' position paper on medication-related osteo­necrosis of the jaw ^[6]. I suppose I didn’t fully appreciate the risk of going forward with an implant.

I did some further research on the issue and I was surprised by the seemingly uniform conclusion that im­plants are very risky for those who have been exposed to bis­phos­pho­nate ther­apy. Many of the studies and reports deal only with oral bis­phos­pho­nates, which are viewed as somewhat less risky than bis­phos­phonates admin­istered in­tra­venously. But the risk asso­ci­ated with an implant is con­sidered to be sig­nif­i­cant, even if the patient has not pre­vi­ously been diag­nosed with ONJ.

I have heard of recom­men­da­tions that patients on bis­phos­phonates who require oral surgery take a one- to three-month bis­phos­phonate drug holiday before scheduling oral surgery. In my case, this might have pro­vided a basis for going forward with an implant after a waiting period. But the position paper I mentioned earlier concludes that the efficacy of such a drug holiday is unproven. This makes some sense since, as my oral surgeon explained, the half-life of bis­phos­phonates can be up to 14 years! That stuff really hangs on.

Clearly, tempting fate is not worth the risk.

So here I am with an unexpected gap in my mouth. It is near the back, so really only noticeable if you know that it is there. I could get a bridge, but that would require that one of the teeth next to the gap – which is perfectly healthy, never having been drilled or capped – be ground down to sup­port the bridge.

For now, I am doing nothing, trying to come to terms with yet another unexpected twist in the road. I am ap­proach­ing it with a smile – just not one broad enough to reveal the gap!