DrBicuspid.com is pleased to present the next installment of Leaders in Dentistry, a series of interviews with researchers, practitioners, and opinion leaders who are influencing the practice of dentistry.
We spoke with Elizabeth Feldman, DMD, a maxillofacial prosthodontist and dental oncologist at the University of Florida Cancer Center Orlando, who discussed mucositis, treatment options, and dental care for oral cancer patients.
DrBicuspid.com: Could you describe what kind of patients you treat?
Dr. Feldman: I see about 50 patients per week who have been diagnosed with oral, breast, prostate, and brain cancers, who are scheduled for radiation treatment and/or chemotherapy. The majority of them have head and neck cancer. Most head and neck patients are middle-aged, but we do have some young patients. Most cancer patients will tell you they've never had any medical problems until they were diagnosed with cancer. Patients come from all over, as far as Egypt, Europe, and Puerto Rico.
Elizabeth Feldman, DMD, a maxillofacial prosthodontist and dental oncologist at the University of Florida Cancer Center Orlando, with patient Ingrid Hellender, who was diagnosed with sinus cancer. Image courtesy of the University of Florida Cancer Center Orlando.I recommend that every head and neck cancer patient have a dental evaluation prior to treatment and be treated aggressively to eliminate any infections, bacteria, and any complications with their teeth. I work with hematology, oncology, radiation oncologists, and head and neck surgeons.
I have a dual specialty -- I see head and neck cancer patients and I also see patients with osteonecrosis. I see the head and neck cancer patients from the beginning of their treatment. I do prosthetic rehabilitation and follow them before and throughout radiation treatment, basically for their lifetime, to make sure their teeth do not decay. I also see the osteonecrosis patients on a daily basis.
When you're thinking about head and neck radiation therapy, there's five complications: rampant dental decay, osteoradionecrosis, mucositis, loss of taste, and decreased mouth opening. These are the most common complications of radiation therapy for patients.
Is head and neck cancer difficult to detect?
It is. Patients often will go from doctor to doctor trying to be diagnosed. They usually know there's something wrong with them. Sometimes, they're placed on antibiotics for weeks on end, thinking that it's a type of infection. My rule is: If it doesn't go away in two weeks, you need to see a specialist. And you need to insist on having a CT scan done or be referred to head and neck specialist, an ENT [ear, nose, and throat] specialist, or an oral maxillofacial surgeon who will understand the symptoms.
Oral cancer tests used by dentists are good and are part of the armamentarium, but there's nothing like a proven biopsy. You have to be persistent and be referred to somebody who deals with head and neck specialists, who is an ENT specialist or an oral maxillofacial surgeon.
Are you seeing more human papillomavirus (HPV)-related oral cancer?
It's very true that HPV-related oral cancer is on the rise. Most middle-aged oral cancer patients were smokers and/or drinkers -- the traditional risk factors. Most of the young patients have HPV-related oral cancer, but many have squamous cell carcinoma.
How are young people getting HPV-related oral cancer?
Because kids in school are not practicing traditional types of sex, and they consider oral sex is not real sex. I also think oral sex is being practiced more these days. Young people may think it's safer and think they're not spreading infections like STDs [sexually transmitted diseases]. Also, the more partners you have, the more you tend to spread HPV.
There needs to be more public awareness of the HPV vaccine for young people. It's very important for young people in junior high school to get the vaccine. It's up to pediatricians to discuss the vaccine with parents.
Could you discuss the issue of oral mucositis and how you treat it?
It's one of the most debilitating side effects of radiation treatment and chemotherapy for patients. Symptoms include small ulcerations on the tongue, buccal mucosa, palate, anywhere in the mouth that has received radiation treatment. It can escalate to very large ulcerations that debilitate the patient's ability to swallow, talk, and eat.
First, I educate patients about what mucositis is. Then we have an oral rinse protocol at the center. They are followed before radiation and also during and after treatment. Mucositis usually starts about the second or third week of treatment, mostly after radiation treatment. It lasts up to two to three months after radiation treatment is finished. Patients can continue to have some complications, even months after treatment is finished. Patients will be prescribed a mucosal protectant, like Gelclair, and I also prescribe a calcium phosphate rinse along with baking soda rinses.
The treatments I use work pretty well, but there is a lot of research going on about mucositis therapy.
I make sure patients get through treatment and have what they need to get through treatment -- whether it's motivational, whether it's medication. And then have them live the rest of their lives without thinking about their treatment.
I helped develop the Oral Mucositis Care app by Dara BioSciences, which I recommend to patients. It talks about getting through mucositis and what it is. It gives a good scenario of treatment and how treatment goes; everything I discuss with patients is on the app. Sometimes when you don't have your doctor around or you're at home, it's nice to look at the app to refresh your memory about what you should be doing.
Where do you think we will see the next big breakthrough for oral cancer -- treatment or prevention?
I would like to see more efforts on prevention. The best preventions involve not smoking and moderate alcohol consumption since most cancers are still squamous cell carcinoma. The HPV vaccine also is useful for prevention.
