DEAR DR. ROACH: My dentist saw a large mass on my jaw and sent me to an oral surgeon, who said the mass was too large. He sent me to a maxillo-facial surgeon, who did a scan and biopsy. I was diagnosed with Paget's disease but the surgeon had never seen a case before and sent me to a rheumatologist. That doctor sent me for a blood test and a full body scan, which found that it is also on my spine. The rheumatologist couldn't give me much information either. I am hoping that you can tell me what this is and what any treatment or long-term side effects are.
ANSWER: Paget's disease of bone is a disorder of bone metabolism. It happens usually in people over 55, and the diagnosis is often made by incidental finding of abnormal blood tests, especially the alkaline phosphatase. It may also be found when a painful bone lesion is X-rayed, and as in your case, people often have several other areas that are usually not symptomatic. Paget's disease is very common, affecting 2% to 9% of older adults, but it is frequently not diagnosed. Examples of this bone disease can be found in ancient history, potentially back to the time of the Neanderthals. Paget's disease can be found in any of your 206 bones, but the skull and spine are the most common sites. The underlying cause is unknown.
Not everyone with Paget's disease needs to be treated. People with symptoms due to Paget's should be treated, as well as people without symptoms but who have "active" disease (as measured by blood tests). People with disease in a critical location may benefit from treatment. The first-line treatment is similar to that for osteoporosis, with medicines like alendronate (Fosamax) or zoledronic acid (Reclast or Zometa).
Without treatment, Paget's disease tends to progress, so the mass in your jaw would be expected to become larger and could cause mechanical problems, put pressure on an important structure (such as a nerve) or even fracture. While unproven, most experts believe treatment reduces long term risk. Treatment definitely reduces pain in most with pain due to Paget's.
DR. ROACH WRITES: A recent column on the side effects of anticoagulation -- easy bruising and tearing of skin -- had many readers asking about the left atrial appendage closure device Watchman. This device has been placed over 90,000 times according to its manufacturer, and the goal is to prevent clots from forming in the first place. Watchman does not treat the underlying abnormal heart rhythm, but does reduce risk of stroke.
I re-reviewed the safety and efficacy data for the Watchman device and find that it remains a reasonable option for people with atrial fibrillation and without a heart valve problem who are unable or unwilling to take anticoagulation. It is true that blood clots may still occur with the Watchman device and that there are occasional complications with the device, such as pericardial effusion (fluid around the heart). However, overall it has similar efficacy and safety as anticoagulation. The data suggest that as physicians gain more experience with the device, the rates of adverse events are going down. Finally, patients using the Watchman device report a better quality of life than those using warfarin.
A reader and a wound care nurse also noted that keeping skin moisturized and supple reduces bruising and especially makes skin less likely to tear. Other readers wrote to be sure the reader wasn't taking supplements (such as turmeric) that could potentially cause bleeding problems. Finally, several readers recommended over-the-counter blood clotting agents. One reader mentioned WoundSeal, Curad's Blood Stop and BleedArrest. As always, I appreciate the helpful comments and suggestions.