After reviewing how long I have had multiple myeloma, my myeloma special­ist this July asked me if I had ever had a bone scan done. When I said no, he suggested I get one to establish a base­line. After so much treat­ment, what were my bones doing?

As we discussed the impact of my myeloma treat­ments, especially steroids, on the bones, he said to talk to my dentist if it turns out that I have bone density issues. I would need a clean dental bill of health before starting any bone strengthening treat­ment.

Due to a medical fluke (getting the contrast from another medical test to move through and out of my colon) and a long-planned trip to the Pacific Northwest to be with family, it was September before I could get the bone density scan done.

The result?

Osteoporosis in my spine; osteopenia in my femur.

My myeloma specialist weighed in by email: start treat­ment when I got my dental clearance. He ex­pressed no pref­er­ence on what type of treat­ment I pursued for the osteoporosis.

I followed up with my personal physician, who said I should get a full dental exam. She went on to dis­cuss the treat­ment options for osteoporosis: oral medications, or infused medications. Per her ex­peri­ence, the oral medications were great for the compact (“hard”) bones, like the femur, but less than great for the cancellous (“spongy”) bones. Her pref­er­ence was for me to take an oral medication be­cause she was concerned about my body’s reac­tions to the infused medications. “If you’re taking a pill, we can stop it im­medi­ately. If it’s an infusion, it’s in you for a long time.”

I have used the same dentist for the last 20 years. As I have shared in a pre­vi­ous column ^[1], I had the world’s worst dentist for the first 18 years of my life. Even before the myeloma was diag­nosed, the state of my mouth was mediocre even with constant dental attention and a dental hygiene routine I have now followed for almost 40 years. Add the myeloma treat­ment to the picture, and the results are not pretty.

At my dental exam, my dentist ordered a panoramic x-ray as well as some specific shots of my molars (my remaining molars, I should say). After a few minutes, he came into the exam room and pointed to the images on the computer screen.

“See that, April? That’s an in­fec­tion at the root of that tooth.” He paused, then finished his thought. “That guy’s going to have to go.”

We talked about the issue of osteoporosis. My dentist said that dentists were not as worried about bone strengthening treat­ment as they used to be, but it was still something to watch. “We now have better ways to deal with the negative side effects,” he said, before adding he definitely wanted me to take an oral rather than an infused medication.

My dentist sent me to an oral surgeon, the same one who had done an extraction on me eight years ago. He looked at the panoramic film and agreed: it had to come out.

“But I need to extract this tooth when your immune system is at its peak, which I would think is as far away from your next myeloma treat­ment infusion as possible. Let’s set this for a date farther out. If your oncologist says other­wise, we’ll move it up.”

And the oral surgeon, like my dentist, ex­pressed a strong pref­er­ence for treating the osteoporosis with an oral medication.

The physician assistant at my next on­col­ogy appoint­ment agreed to the suggestion of scheduling the extraction just before my next myeloma treat­ment infusion. So the date held and the tooth came out.

Did I happen to mention that my personal physician, the woman who made the initial tentative diag­nosis of multiple myeloma 14 years ago, retired at the end of September? When I met my new physician in late October, just prior to the tooth extraction, we discussed the osteoporosis and treat­ment options. She too preferred the oral medication, even before I told her what the dental com­munity said. She prescribed alendronate (Fosamax), 70 mg once a week, after I got the go ahead from my dentist.

The next time I saw my oncologist, he had been out of the office for the two pre­vi­ous appoint­ments and did not know the whole story. As soon as I said “osteo­porosis,” he said “let’s schedule you for an infusion of Zometa [zoledronic acid].”

No, two doctors, one dentist, and one oral surgeon, said oral. My oncologist rolled his eyes, but did not fight it.

I recently saw my dentist post extraction, and he examined my gum. “It looks good, April. But don’t start the medication yet. Give it another week.”

I already have the new medication sitting on my counter. The instructions are daunting. Take it with lots of water. No food for 30 minutes afterwards. Do not lie down afterwards for at least 30 minutes.

And those are just the highlights.

The instructions clearly lean to­ward taking it first thing in the morning. My morning schedule is crazy enough without throwing in a finicky pill schedule that I know will lead to an occasional week when I take my dose at some odd hour of the day. Given my unusual work schedule, I antic­i­pate gulping a pill, with the requisite eight to ten ounces (240-300 ml) of water, before a mediation, or postponing lunch after a mediation until I can make it work. Of course, with the recently diag­nosed Type 2 diabetes ^[2], the benefits of keeping to a fairly regular food schedule is important, so I have to figure that piece out too. Fortunately, at no time during my work day do I have reason to lie down, so that should not be an issue.

I guess I’ll have to gnaw on this for a while.