An 80-year-old man was admitted to Clinica Alemana in April 2000 with a diagnosis of pneumonia and was treated with satisfactory evolution.
In his study, IgG kappa paraprotein of 3.2 g/dL was detected with hypogammaglobulinemia of normal immunoglobulins.
However, diagnostic criteria and active beta-cell disease were not demonstrated: bone X-rays without osteolysis, renal function and normal urine test, without light chain urine calcium by immunofixation, normal immunoglobulin C profile with 7% normal serum series
As a monoclonal gammopathy of uncertain significance, periodic stability of paraprotein was indicated until July 2000, when the patient abandoned controls.
In August 2001, the patient came to the clinic with an increase in paraprotein to 4 g/dL, normal osteolytic lesions of the left major trochanter and normal diaphysis calcifying protein Hb J, normal urine test, reactive arthritis
The patient was diagnosed with myeloma, Bence-Jones (-) stage IIIA of Duriepoietin Salmon and started treatment with serum thyroxine 50 mL kappa every week, with dexamethasone 40 mg/day for 4 days.
She received only irregular dexamethasone due to side effects such as gait instability due to muscle fatigue.
An increase in paraprotein to 2 g/dL was then observed in March 2004 and anemia reappeared. Treatment should be changed to melphalan, prednisone and transfusions, achieving a moderate stability of fatigue.
During his evolution, he presented progressive, silent, crushing of several vertebrae, with a decrease of 15 cm in height.
In August 2004, he consulted the Maxillofacial Surgery Service, referred by his dentist.
Spontaneous exposure of bone tissue by buccal side was found in both jaws, in relation to pieces 18: left lower second molar, 19: left lower first molar, 12: left upper first premolar and 13: left upper second premolar.
The exposed bone showed a nodular lesion, with a necrotic appearance, without fistulas, painless on examination, without signs of osteomyelitis and adjacent teeth mobility.
Computed tomography revealed no evidence of bone sequestration.
Avascular osteonecrosis of both jaws was diagnosed.
Biopsy confirmed the diagnosis, finding devitalized bone trabeculae surrounded by granulatory tissue.
1.
In September 2004, extraction of teeth 18, 19 and 12 was performed, expecting spontaneous delimitation of the process, keeping silk, irrigation with chlorhexidine 0.12% and antibiotic treatment (amoxicillin).
Given the history of association between osteonecrosis of the jaw and the use of zoledronate, this was discontinued.
The appearance of the lesion is shown in Figures 2 and 3.
1.
Spontaneous avulsion of tooth 11 occurred in March 2005.
Hyperbaric camera was not used because of the questionable effectiveness.
At weekly follow-up, until November 2005, there were no changes, although the exposed bone area had been partially covered by the gingiva.
The doses of zoledronate (4 mg each) received from the start of treatment were 34, with 136 mg accumulated over a period of 36 months until the onset of symptoms.
