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FACT SHEET: Myeloma (Multiple Myeloma) (includes “smouldering multiple myeloma” [also known as “indolent multiple myeloma”]; active multiple myeloma [also known as “symptomatic multiple myeloma”]; “solitary plasmacytoma of the bone” [also known as “isolated plasmacytoma of the bone”]; “extramedullary plasmacytoma”; “light chain multiple myeloma”; and “non-secretory myeloma”)

Date of Publication: January 31, 2019
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Note: Unless otherwise specified, this fact sheet primarily addresses active multiple myeloma (MM). Also, the therapeutic modalities of chemotherapy, radiation therapy, and hematopoietic cell transplantation, as well as medication-related osteonecrosis of the jaw (MRONJ), are addressed in detail in separate fact sheets.

Is the initiation of non-invasive dental hygiene procedures* contra-indicated?

  • Unlikely, but depends on severity and type of myeloma, severity of complications arising from treatment, and procedure being contemplated.

Is medical consult advised?  

  • Yes, if the patient/client is undergoing chemotherapy and has, or is suspected to have, certain oral conditions or systemic manifestations.
  • Yes, if the patient/client is about to undergo, or is undergoing, radiation therapy.
  • Yes, if the patient/client is taking a bisphosphonate (orally, by injection, or intravenously) or other bone antiresorptive agent (e.g., denosumab).
  • Yes, if the patient/client appears debilitated.
  • Yes, if undiagnosed myeloma is suspected.

Is the initiation of invasive dental hygiene procedures contra-indicated?**

  • Yes. This is a blood disorder as per Ontario Regulation 501/07 pursuant to the Dental Hygiene Act, 1991. Multiple myeloma may affect appropriateness or safety, and scaling and root planing, including curetting of surrounding tissue, are contraindicated until the patient/client is medically cleared. Other possible contra-indications include active chemotherapy and/or radiation therapy, as well as significant immunosuppression and/or bleeding disorder (e.g., thrombocytopenia) resulting from the disease itself and/or its treatment.

Is medical consult advised? 

  • See above. Additionally, pre- and post-radiotherapy/chemotherapy medical and/or dental consultation is often warranted.

Is medical clearance required?

  • Yes, if myeloma has been diagnosed or is suspected.
  • Yes, if the patient/client is undergoing radiotherapy and/or chemotherapy.
  • Yes, if immunosuppression exists or is suspected (whether from the disease itself1 and/or its treatment).
  • Yes, if patient/client is being treated with medications (such as corticosteroids or immunomodulators) associated with immunosuppression +/- increased risk of infection.
  • Yes, if thrombocytopenia exists or is suspected (whether from the disease itself and/or its treatment).
  • Yes, if severe anemia exists or is suspected (whether from the disease itself and/or its treatment).
  • Yes, if MRONJ exists or is suspected.
  • Yes, if the patient/client is being treated with an anticoagulant (e.g., warfarin or a novel oral anticoagulant [NOAC])2.

Is antibiotic prophylaxis required? 

  • Possibly, for some patients/clients according to blood indices (e.g., low neutrophil count) that indicate immunosuppression resulting from the disease itself and/or from chemotherapy and/or radiotherapy3. Furthermore, some patients/clients may require intravenous immunoglobulin (IVIG) to prevent infection.

Is postponing treatment advised? 

  • Possibly, depending on blood indices (which indicate degree of immunosuppression and/or thrombocytopenia and/or anemia) in patients/clients undergoing chemotherapy or radiotherapy. Elective invasive procedures should be deferred until after chemo- or radiation-induced immunosuppression ceases.
  • In the case of hematopoietic cell transplantation, elective oral procedures, including scaling and polishing, should be delayed until the patient/client’s immune system returns to normal; typically this takes 3 to12 months post-transplantation.

Oral management implications

  • Refer to Chemotherapy, Radiation Therapy, Hematopoietic Cell Transplantation, Xerostomia, and MRONJ Fact Sheets, as applicable.
  • Because patients/clients with multiple myeloma often have significant bone pain (especially in the back), short appointments and/or frequent breaks and/or careful positioning of the dental chair and/or frequent repositioning of the patient/client may be indicated for dental hygiene treatment. 
  • Because many patients/clients with extramedullary plasmacytoma (see below) will eventually develop multiple myeloma, detection of a single tumour of plasma cells requires evaluation to determine whether the lesion is solitary or part of multiple myeloma.
  • In patients/clients with already diagnosed multiple myeloma, the dental hygienist should be alert for the presence of hard and/or soft tissue masses that could indicate the deposition of plasma cells and/or light chain associated amyloid4.

Oral manifestations

  • Refer also to Chemotherapy, Radiation Therapy, Hematopoietic Cell Transplantation, Xerostomia, and MRONJ Fact Sheets   for details regarding cancer treatment-related dry mouth, caries, mouth sores, gingival bleeding, dysgeusia (unpleasant taste), infections, periodontitis, and osteonecrosis.
  • Myeloma lesions in the jaw bone and/or oral soft tissues, as well deposits of amyloid in the oral soft tissues, may occur in patients/clients with MM. While uncommon, the first manifestation of disease may appear in the jaw bones or oral cavity, with oral manifestations (including osteolytic lesions in the jaw) eventually occurring in 14% to 30% of patients/clients. 
  • Petechiae, ecchymoses, and gingival bleeding can result from thrombocytopenia.
  • Macroglossia can result from amyloid deposition in the tongue. An enlarged tongue can lead to problems swallowing and breathing during sleep (obstructive sleep apnea).
  • Pain and swelling in the oral cavity or jaws, tooth mobility/migration, burning mouth syndrome, paleness of mucosa, and/or epulis5 formation may occur.
  • Oral candidiasis and other opportunistic infections such as recurrent (secondary) oral herpetic infection may result from immunosuppression due to the disease itself and/or treatment.
  • Radiographically, multiple well-defined radiolucencies (“punched-out lesions”) may be seen in the skull and jaws of patients/clients with multiple myeloma. Up to 30% of patients/clients with MM eventually have jaw involvement, with the mandible being affected more frequently than the maxilla, and posterior portions of the jaw being more commonly affected than anterior.
  • Medication-related osteonecrosis of the jaw may result from use of bone antiresorptive agents.
  • Solitary plasmacytomas6 of bone do not often occur in the jaws, but when they do, they are usually located in the angle of the mandible. Radiographically, a solitary plasmacytoma is a well-defined lytic lesion that may be multilocular.
  • In soft tissue, a localized tumour of plasma cells is called an extramedullary plasmacytoma. Although rare, these tumours are more common in the head and neck than elsewhere in the body, with about 80% of all such plasmacytomas arising in the oral cavity and upper respiratory tract7. The lesion appears as a dark red, fleshy mass that rarely ulcerates.
  • Risk of secondary malignancy is elevated in patients/clients treated for MM, particularly squamous cell carcinoma including in the oral cavity.

Related signs and symptoms

  • Multiple myeloma is a systemic, malignant proliferation of cloned plasma cells8, which results in destructive lesions in bone.9 The cancerous plasma cells (also known as myeloma cells) produce large amounts of immunoglobulin proteins10. 
  • MM is the third most common blood cancer after lymphoma and leukemia. Annually, about 3,800 persons in Canada (1,720 in Ontario) are diagnosed with multiple myeloma (representing about 10% of hematologic cancers) and about 1,600 (600) die from the disease. The 5-year survival rate for multiple myeloma is about 50%11, with new treatment modalities dramatically improving prognosis and increasing prevalence.
  • Most patients/clients are older than 50 years of age, with disease onset most commonly occurring in the seventh decade of life. Men are affected more frequently than women.
  • Malignant plasma cells can:
    • disrupt (“crowd out”) normal red blood cell production, leading to anemia;
    • disrupt normal platelet production, leading to thrombocytopenia (and hence nosebleeds, easy bruising, and excessive bleeding from minor cuts and scrapes);
    • disrupt normal white blood cell production, leading to leukopenia and thus interfering with the functioning of the immune system, resulting in frequent and/or aggressive infections (including pneumonia due to neutropenia)12;
    • dissolve and weaken bone, resulting in osteopenia/osteoporosis, pain, pathologic fractures, and/or collapse of vertebrae;
    • damage the kidneys (particularly in light chain myeloma13), leading to renal failure, which may be acute or chronic in nature; and 
    • form into a mass (i.e., plasmacytoma).
  • Signs and symptoms of multiple myeloma often appear as the tumours grow in the bone marrow or outside of the bone marrow and/or as a result of immunoglobulins building up in organs (particularly the kidneys). MM commonly presents as bone pain, fatigue, and anemia. The most common signs/symptoms of MM are referred to as CRAB, which stands for:
    • Elevated blood calcium level;
    • renal insufficiency;
    • anemia; and
    • bone disease. 
  • In advanced disease, hypercalcemia (i.e., high level of calcium in the blood) results from bone damage. Signs/symptoms include lethargy, extreme thirst, frequent urination, nausea, vomiting, dehydration, constipation, abdominal pain, loss of appetite, weakness, drowsiness, confusion, and headache. Peripheral neuropathy (including tingling of fingers and toes) and kidney failure can occur. If serum calcium level rises high enough, coma, and even death, can result. 
  • Systemic amyloidosis occurs in about 10% of patients/clients with multiple myeloma, resulting from excess immunoglobulin light chain production and accumulation. Deposits occur in various organs and tissues, replacing normal tissues and resulting in organ dysfunction, including kidney failure and heart failure. Skin changes include changes in colour and/or texture. Carpal tunnel syndrome may occur, which causes numbness and weakness in the hands. 
  • Risk of stroke is increased in multiple myeloma due to hyperviscosity of the blood.
  • Neurological problems — including numbness and tingling, muscle weakness, paralysis, confusion and dizziness — may occur, some of which may be related to spinal cord compression14, which is a medical emergency.
  • Weight loss, weakness, fever, and shortness of breath (due to anemia) are common in active multiple myeloma.
  • While the cause of multiple myeloma is unknown, certain chromosomal (genetic) abnormalities are common.
  • Unlike patients/clients with multiple myeloma, those with solitary plasmacytoma of the bone have a normal peripheral blood picture and a normal clinical chemistry profile. 
  • Radiographically, affected bones in multiple myeloma show multiple radiolucent (hypodense) lesions. In addition to the skull and jaws, MM often involves the spine, ribs, pelvis, and long bones (i.e., humerus and femur).
  • Myeloma is known as a relapsing-remitting cancer, meaning that patients/clients tend to alternate between signs/symptoms that need to be treated and stable disease that does not require treatment (remission).
  • While there is as yet no definitive cure for multiple myeloma, there are many treatment options for the disease itself as well as for management of its signs/symptoms. Treatment includes an individually tailored combination of:
    • watchful waiting for asymptomatic smouldering multiple myeloma15;
    • chemotherapy;
    • high dose chemotherapy as a prelude to stem cell transplantation);
    • radiation therapy (to treat a bone tumour or for palliative therapy of bone pain);
    • immunomodulatory drugs16 (which interfere with the growth and reproduction of myeloma cells);
    • proteasome inhibitors17 (which inhibit plasma cell growth and reproduction and promote the death of abnormal plasma cells);
    • plasmapheresis18 (which is sometimes used to remove myeloma cells from the blood and hence decrease hyperviscosity);
    • corticosteroids (often in combination with chemotherapy);
    • systemic bisphosphonates (which are used to prevent bone destruction);
    • colony-stimulating factors (CSFs; which are drugs that promote formation of new red and white blood cells19); and
    • surgery20.
  • Most patients/clients with myeloma die from infection or renal failure, and less commonly from cardiac complications or hematologic complications of hemorrhage or thrombosis.

References and sources of more detailed information


Date: December 20, 2017
Revised: March 25, 2022


FOOTNOTES

1 Multiple myeloma can cause immunosuppression via leukopenia (i.e., low white blood cell count; neutropenia — low neutrophil count — is a particular concern) and/or via hypogammaglobulinemia.
2 Patients/clients with multiple myeloma are at increased risk of venous thromboembolism due to the disease itself, as well as due to treatment with certain medications (e.g., thalidomide and its analogues). Hence, patients/clients may be taking anticoagulant medication.
3 Total body irradiation for bone marrow/stem cell transplantation purposes is a particular concern.
4 Amyloid (i.e., deposition of complex proteins in tissue) occurs in multiple myeloma as a result of aggregation of immunoglobulin light-chain proteins.
5 An epulis is a tumour-like enlargement (“lump”) on the gingival or alveolar mucosa.
6 When a solitary plasmacytoma develops in bone, it is called an isolated plasmacytoma of the bone. Less frequently, a solitary plasmacytoma starts in other tissues, where it is referred to as extramedullary. At least 1/3 of people with solitary plasmacytomas will eventually develop other plasmacytomas and hence multiple myeloma.
7 The upper respiratory tract includes the pharynx, paranasal sinuses, nasal cavity and larynx.
8 A plasma cell is a type of immune cell that makes a specific antibody (i.e., immunoglobulin). It is a fully mature, differentiated form of a B-lymphocyte, a type of white blood cell. Plasma cells are found primarily in bone marrow, but they are also present in other tissues and organs.
9 Diagnosis of multiple myeloma is established by a combination of some of the following investigations: quantitative immunoglobulin (Ig) blood test; protein electrophoresis of the blood and/or urine; bone marrow biopsy; cytogenetic testing; skeletal survey x-rays; calcium blood level; red cell blood count; and kidney function tests. In addition, magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography (PET) may be used to scan the body to assess the spread of the cancer.
10 Most patients/clients with myeloma have an elevation of a single (“monoclonal”) type of immunoglobulin (e.g., IgG, IgA, etc.) that manifests as a monoclonal spike in immunoelectrophoresis. In the urine, fragments of immunoglobulins are known as Bence-Jones proteins.
11 Five-year net survival rate is for ages 15-99 years.
12 In addition to neutropenia and other forms of leukopenia, diffuse hypogammaglobulinemia (an immune deficiency state) results from decreased production of normal antibodies.
13 In persons with light chain myeloma (representing 15% to 20% of patients/clients with myeloma), the myeloma cells don’t make a complete immunoglobulin. Instead, the myeloma cells only make the light chain component of the immunoglobulin, and not the heavy chain.
14 Spinal cord compression should be suspected if there is sudden, severe back pain accompanied by numbness and muscle weakness in the legs.
15 Most persons with smouldering multiple myeloma will eventually develop symptomatic active multiple myeloma.
16 Thalidomide and its analogs (e.g., lenalidomide) are antiangiogenic immunomodulators.
17 Bortezomib, carfilzomib, and ixazomid are proteasome inhibitors used to treat MM.
18 Plasmapheresis is a blood-cleansing process in which plasma is removed from the body, treated to remove undesirable components (such as myeloma cells), and then returned to the body. Alternatively, the removed plasma may be exchanged for good plasma (from plasma donors).
19 For example, recombinant erythropoietin is used to stimulate red blood cell production, and filgrastim is used to stimulate neutrophils.
20 While surgery may be employed to excise a solitary plasmacytoma, it is rarely used to treat multiple myeloma, which is mulifocal in nature. However, emergency surgery may be needed to address spinal cord compression, and elective surgery is a consideration for insertion of metal rods or plates to support weakened bones or to treat fractures.


* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.