Sir, having been diagnosed with multiple myeloma in 2004, I read the recent paper by Ariyaratnam et al. (BDJ 2005; 199: 433–435) with particular attention.

While the case report is interesting, few dentists will see such an atypical presentation. On the other hand, they will come across patients with multiple myeloma and I was disappointed by the discussion of this condition. Too much of the information in this section has been gleaned from outdated sources. Specifically, I would draw the authors' attention to the following points.

The limitation of the staging system of Durie-Salmon has been recognised and it has been replaced by the new International Staging System (ISS).1 Following a collaborative effort by investigators from 17 institutions worldwide, patients can be divided into three distinct stages and prognostic groups solely on the basis of serum 2-microglobulin and albumin levels.

The use of melphalan is nowadays usually limited to older patients who are not candidates for stem cell transplant since it can prevent adequate stem cell mobilisation. Even the role of autologous stem cell transplants is being questioned, as they seem to offer the greatest benefit to those with disease refractory to induction therapy. Amongst the newer treatments, Thalidomide has been used extensively for the past five years but may produce severe side effects, including permanent peripheral neuropathy, when used in high doses. Greater success without neurotoxicity has been reported for Revlimid (lenalidomide), an analogue of Thalidomide. Another widely used new treatment is Velcade (bortezomid). All of these drugs may be more effective when used in combinations with each other and with steroids such as dexamethasone or prednisolone. Promising current research includes monoclonal antibodies and Heat Shock Protein (Hsp90) inhibitor.

However, the most serious omission was any reference to the problem of jaw osteonecrosis following prolonged use of bisphosphonates such as Aredia (pamidronate) and Zometa (zoledronic acid). This has been widely reported since 2003 and indeed mentioned in two recent editions of this journal.2 These drugs are routinely administered by monthly infusion to myeloma patients to prevent bone damage but may trigger problems with bone healing in a small subset of patients following dental surgery. This includes tooth extraction, endodontics and periodontal treatment. Close cooperation is required with the patient's haematologist in these circumstances and it may be advisable to stop the bisphosphonates for three months before any treatment.

Therefore, my advice to any dentist faced with a patient with myeloma would be:

  • Check on the International Myeloma Foundation website at www.myeloma.org.uk to update yourself on the condition.

  • Fully investigate and note the patient's past and present treatment and medication.

  • Contact the patient's haematologist, particularly if any surgery is required.

The aim of contemporary treatment should be to characterise the myeloma, ideally at a molecular level, and tailor the treatment to the individual patient. I noted the authors' gloomy statement, 'myeloma ultimately leads to death'. well, yes — but life itself is a fatal complaint and does not consist of holding good cards but in playing those you hold well!