Be good to your creature...and it will be good to you

by Charles Wakefield, DDS, MAGD, ABGD, FICD, FACD

The first thing we hear during airplane takeoff preparation is a directive to place the oxygen mask on ourselves before assisting others. That’s good advice for most of what we do in order to live productive, satisfying, active, exemplary lives. Take care of yourself; the returns are well worth it!

I have known more than a few fellow dentists who have had their careers cut short or completely modified due to illness or injury. Chronic medical conditions become more severe, cardiovascular conditions dramatically limit practice and lifestyle, cervical or lumbar problems eliminate the ability to practice, and some illnesses just appear out of the blue. When we’re young we believe we’re bulletproof, and when we’re older we think we’re too busy to get sick.

We should make sure we have all of our assets, including practice, life, home and family insured and protected completely, because we never know when something bad is going to happen. Most of all, we should have a regular exercise routine, manage weight and diet, not smoke and have a thorough physical examination at least annually. That doesn’t mean we can’t overdo the dip or enjoy some good wine during the game!

I have always been very active in many sports, including team sports, running, and cycling. As a member of running and cycling clubs, it’s routine for me to ride a bicycle over 100 miles on Saturdays during cycling season, and I’ve run many full marathons. I joke with friends that if we exercise and have that heart attack, at least we’ll live through it because we’ll have collateral vascularity. I’ve seen this occur as my friends and I get older. Aging and the subsequent changes that happen can sometimes be a dramatic surprise.

At the age of 57, after a very good season of cycling and everything checking out optimally on my extensive annual physical exam, my excellent internal medicine physician said one test was very abnormal - the erythrocyte sedimentation rate (ESR), or sed rate. During my residency, we learned that an abnormal sed rate was indicative of an occult process warranting further investigation. Almost no physical exam these days uses this cheap lab test that costs about $15, so make sure you request an ESR. Mine was alarmingly high, and my physician ordered more tests. It was strange to say the least because I felt in perfect health.

Several days later, the doctor told me he suspected that I had multiple myeloma, a malignancy of bone marrow plasma cells. His office arranged an immediate myriad of tests in the hospital through hematology/oncology, including X-rays, blood studies and bone marrow aspirations. Some of these tests were a whole new adventure to me! Diagnosis was confirmed and the chemo started within a week, and my lifestyle came to a screeching halt.

As the director of a graduate residency program at a university dental school and a frequent national and international speaker, I was booked solid for a couple of years in advance. I didn’t feel like doing much while I was taking 200 mg of Thalidomide every day, and the resultant severe neuropathy (among other side effects) affected my clinical skills in a hurry.

My antidote for this lethargy was to force myself to continue exercising vigorously at least 60 to 90 minutes per day. I figured I would stress my marrow to make good cells and assure high levels of collateral circulation to minimize the neuropathy. I found that this regimen, although difficult, allowed me to function relatively normally throughout the day and keep my speaking obligations for the time being. In addition, I was given 90 mg of IV pamidronate (Aredia) monthly, which is one of the bisphosphonate drugs that have gained acute attention for being associated with avascular bone necrosis of the jaws. Because of this potential I was not allowed to even be a patient in my own dental school. It’s a good thing one of my sons is a dentist who could see me!

This bisphosphonate related osteonecrosis has not been reported anywhere except the jaws. After I attended the multiple myeloma support group meeting a couple of times, I realized most of the patients had severe problems with their chemotherapy and experienced vertebral compression fractures and severely limited mobility. Many were wheelchair bound. Their knowledge of dental involvement and the importance of oral care and potential systemic effects were nearly nonexistent. Many patients didn’t discover a problem until they had suffered sudden multiple fractures, which led to the diagnosis of multiple myeloma. It really helps to get routine complete exams, have a really smart physician, and be in good physical condition going into treatment.

Eight months later, the malignant plasma cells in my marrow had decreased, so the chemo was working. The next step was an autologous stem cell transplant, also called a bone marrow transplant. At that point, I had to tell my residents I’d be gone for at least two months, and I had to cancel nearly a year of speaking engagements. More tests and procedures awaited me. I had to go to the operating room for ports to be inserted in my chest, but once they were in place, I was poked a lot less in order to save my veins for later. I would need them ... they were going to be used a lot.

Next came a process called apheresis. After multiple injections in body fat for several weeks, the marrow produces lots of stem cells that are subsequently harvested by circulating the blood through special equipment. The goal is to harvest at least 10 million stem cells, half of which are used for the transplant and half of which are stored in liquid nitrogen for a future transplant. Now that’s medical security. I know my cells are next door on ice for the next time I want to be off work for a few months.

For three to four weeks in my own semi-isolated hospital room, my marrow was obliterated completely with more chemo - hopefully destroying the malignant sources - and was followed by transplantation of the harvested stem cells. The day of the transplant was called my “second birthday,” so I now have another day to celebrate each year. At that point, the wait began to see if and when engraftment had occurred.

I vaguely remember watching the Olympics in Athens 24/7 from start to finish. It was an adventure to see my lab results on the wall and the white blood cell count at zero for days on end, and platelets and red cells low enough to warrant transfusions. But eventually the counts started to come up and I knew this course of treatment was going to work. Unfortunately, it didn’t work for some other patients I had befriended. It took more than a month at home with daily hospital visits before I was able to return to work. The support I got from friends and coworkers was incredible, but I had to miss my 40th high school reunion.

It’s extremely important to exercise always, even when you don’t feel like it. When I first entered the hospital, I walked the halls dragging my IV at least three miles every morning. The staff told me I wouldn’t be able to make it to the restroom and back to bed soon after the in-house chemo. I laughed at them, but they were right. I didn’t want to look at food. About three months post-transplant, I got on my home elliptical trainer with no resistance and no incline for about five minutes and was exhausted. That motivated me - I refused to remain in this sad condition. I have seen many patients who will never improve because they don’t have the self-discipline or will to reach their potential. That sounds like the motivational talks I give my residents!

Five months after my transplant, I began cycling with my club, the Knuckleheads, and trained as hard as possible, starting from nothing and seeing weekly progress. We worked up to training rides on weekends of more than 100 miles in the Texas heat and even completed the Hotter’N Hell Hundred® 102-mile ride in August in four hours, 20 minutes, averaging 23 mph. This was exactly one year after my transplant. I like setting goals and achieving them. I continue with this program, and the early season training is currently underway.

Autologous transplants have the advantage (when compared to allografts) of minimal graft vs. host reaction, which can be lethal. However, they have the disadvantage of autoinoculation if all the malignant cells aren’t killed by the initial chemo. Post auto-transplant patients still have these malignant cells at least 80 percent of the time, and the disease is subsequently managed by long-term lower levels of chemo drugs. Amazingly, my blood and marrow are in complete remission 28 months post-transplant, and the only medication I take is monthly Aredia, which will continue indefinitely. I even have all my hair again.

Today, I speak to cancer support groups about oral hygiene and the necessity of dental exams and avoidance of extractions. Patients and dentists must be aware of the dangers of bisphosphonate-related osteonecrosis. It is astounding to me how many of these patients weren’t told of the absolute need for definitive dental treatment and maintenance. We must vigorously educate physicians as well. We must take complete medical histories of patients and talk with their doctors, as an increasing number of patients with this condition are out there. Finally, some comprehensive articles are now available in dental literature.

My doctors are amazed at my state of health, and I’m happy to ride this train as long as it keeps going. My attitude tells me it will be for a long time. I’m convinced that my lifestyle, level of exercise, positive attitude and self-discipline are the reasons I’m enjoying my current state of health. I want to emphasize that all of us need to stay in good condition, so if some weird illness pops up as we age, we will be able to deal with it, not only from the medical side of treatment, but from the all-important inner strength we all possess. Through these efforts, we will be able to continue with the profession of dentistry in some productive capacity.

Charles W. Wakefield, DDS, MAGD, ABGD, FICD, FACD, is a Diplomate of both the Federal Services Board of General Dentistry and the American Board of General Dentistry. He is currently a consultant to the Commission on Dental Accreditation of the American Dental Association. He also is a tenured professor in the Department of General Dentistry and director of the Advanced Education in General Dentistry Residency Program at Baylor College of Dentistry, Texas A&M Health Science Center, at Dallas. He can be contacted by e-mail at [email protected].