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AUDIO - HSP #172 - Lauren Levi
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VIDEO - HSP #172 - Lauren Levi
Dental oncology expert Lauren Levi, DMD introduces us to techniques to identify oral cancer.
Trained in dental oncology, Lauren Levi, DMD delivers comprehensive oral care to cancer patients before, during and after therapy. After receiving her D.M.D. at the University of Florida College of Dentistry, she completed a general practice residency at New York Presbyterian-Weill Cornell Medical Center. During her residency, she rotated through Memorial Sloan Kettering Cancer Center, where she discovered her passion for dental oncology. She then pursued a fellowship in dental oncology at Memorial Sloan Kettering Cancer Center. This training equipped her with extensive experience performing dental treatment on patients who are receiving chemotherapy, radiation therapy, and stem cell transplants and those who may face individual dental needs because of these treatment programs.
Lauren Levi, DMD
630 Fifth Ave, Suite 1857
New York, NY 10111
Howard: It is a huge, huge honor for me to be interviewing a rock star in oral cancer. Lauren Levi. did I say it ... Is it Levi?
Howard: Levi, okay. Levi. I don't think the New Orleans people wanted to be reminded of a levi. This is so interesting to me because at my age when I was in dental school, I graduated in "87" you know, you just thought of oral cancer as people who smoked and drink. I always thought that do to a judge mental society, you know it's almost like you had it coming. You smoked a pack a day for 40 years what were you expecting? I never heard once in dental school about a human papillomavirus. Now that's kind of been a game changer in oral cancer. We don't look at oral cancer as just smoking and drinking. We've go t a couple of really famous, a famous movie star Michael Douglas who actually said a word on TV that I didn't even know they'd ever play.
He got it from oral sex and then there's a very famous football player from the Buffalo Bills whose got oral cancer and they're basically insinuating this wasn't from drinking and smoking. I don't think he's came out and said anything. First of all thank you for being on my show.
Lauren: Thanks for having me.
Howard: You've got an hour with thousands of dentist. I think the last podcast had 7,000 listeners and they're mostly all commuting to work. What do you think they should be thinking about when they think of oral cancer?
Lauren: I guess, just like what you were saying that you would always just think of those traditional people of the older men that were smoker and drinkers and don't think that. It doesn't take a very long time to do oral cancer screening even though it seems, might seem like it's not important, it really is. It doesn't take a very long time to do a through history taking so don't forget to ask those crucial questions, even if some of them might be a little uncomfortable. Don't assume anything.
Howard: Okay, verbalize an oral cancer exam.
Lauren: Verbalize? You mean in terms of history thing or what you actually do?
Howard: What you actually do. I think about 85% of my listeners are just audio only. They're listening while they're driving. They can't see you get a patient and give an oral cancer exam. You just have to talk them through it because a lot of people who I see when I'm standing behind a patient as a dentist and I see them do an oral cancer exam, some feel around the filling. 90% are looking inside the mouth. In all honesty, really, I don't see my buddies doing touching. They're looking. Walk me through an oral cancer exam.
Lauren: Okay, so first you definitely want to palpate the head and neck extra early. You want to make sure you're not missing any lymph nodes or glands. Have them turn their heads to the right and the left so you're feeling along the sternocleidomastoid. Don't be afraid to pinch. I feel like a lot of times, at least initially people get scared and they do a quick little feeling and then you don't feel anything. You have to really go for it and palpate. And then you also want to go up and make sure you go behind the ears and in front of the ears as well.
Howard: Really behind the ears?
Lauren: Yeah. Well you know you're just looking right here. Then I always palpate their lips of course. Then you go in and like everybody does, you take that gauze and have then stick their tongue out, hold their tongue. Look to one side and then look to the other. Look in the back of their throat. Have them lift their tongue. Dry the floor of their mouth a little bit. Look there carefully and of course look at the palate, look at the best tools. It doesn't take a very long time but it obviously makes a huge difference.
Howard: What I'm reading is one person dies every hour of oral cancer in just the United States alone.
Lauren: That's horrible.
Howard: Then I got to ask you as a woman, instead a man. How come if you go to a doctor and ask for an exam downstairs the insurance pays and they can do a uterine pap smear and all that is paid, but when I do an oral exam or oral cancer screen on a female in her mouth, most of the insurance don't even pay.
Lauren: That's a good question. Yeah, I don't ...
Howard: Isn't that kind of bizarre that the lower half of your body is worthy of an insurance reimbursement and the upper half of your body is not?
Lauren: No, I think that still goes back to the theory that people think that the mouth is not connected to the rest of the body and a lot of the stuff in the mouth is not covered by the medical insurance.
Lauren: Don't you?
Howard: Yeah, I mean absolutely. I think that the Soviet Union did it so much smarter where Stomatology was just a branch of med school. The first four years need up the same, then the two years and you wanted to be a dermatologist and your buddy wanted to be a gynecologist and another buddy wanted to be a stomatoligst and what I liked the most about that system is if you ever decide you're not good with your hands you only got to do another residency and you go into some other branch of medicine. Where with dentistry you've got to start all over and go to med school. I think it should be corrected, I think ...
Lauren: I agree.
Howard: Because you need, in economics you need fluidity of markets. We like a continual 5% unemployment. Shifting people from lower productivity areas to higher productivity areas. I think health care would be better if nurses and hygienist and dentist and physicians and everybody could move around with more fluid. Then having all these artificial barriers to entry which is crazy.
A lot of dentist are thinking to do an oral cancer exam, I hear of all these products sold. Velscope, toluidine blue rinses. All these things like that. Should I be incorporating that stuff into an oral cancer exam?
Lauren: The studies on those are mixed so I would say, no. I think still the gold standard is just using your eyes and hands. If you see something suspicious biopsy it. Of course there's always that rule of wait two weeks. If I see something very suspicious, I'm not waiting two weeks because who knows when that patient came in.
Howard: You're a lot smarter then me or any of my listeners on the subject of oral cancer. I can assure all my listeners of that. I gather, I don't know who would be listening that would know more than Lauren on this. If I'm palpating something, talk about what I would be feeling that would make me suspicious. I feel a bump.
Lauren: Is it movable?
Howard: Okay, talk about that.
Lauren: Is the bump movable? If it's not movable that's of more concern. Is it indurated. That's of course of concern.
Howard: If it's what?
Lauren: If it's indurated. If it's hard. If it's not movable and if it's indurated, those are two key areas of concern.
Howard: If it's not movable. Are you saying indurated?
Howard: Indurated means not movable ...
Lauren: No, no, no. Indurated meaning hard. Indurated means hard. Then if it's not movable. When you're feeling someone's neck you always feel a lot of lumps and bumps that's normal. Those are just lymph nodes. Sometimes they might be enlarged because the person has allergies or they were just getting over a cold or they were sick. I always ask all those questions if you feel something. Say, "Oh do you have allergies, were you recently sick? Do you feel like you're getting sick?" That sort of thing. If they have bilateral enlarged nodes then it's not as much concerning of course if then if it's one sided. Granted it could be that it already spread but less likely.
Howard: What if we need pinch it and it hurts? It's tender. Is that more likely or less likely to be not good?
Lauren: Cancer usually doesn't hurt but I wouldn't rule that out and just because it hurts don't, I wouldn't say that it's not.
Howard: You feel a hard bump and you can't roll it around and it feels like it's fixed, that's bad because ...
Howard: Because fixed means it's metastasizing so it's attaching to something.
Lauren: Yeah, that's a good way to put it. Fixed, usually when it's fixed it's usually malignant or it's not just a normal malignant that's draining because you had an infection or something or it's not most likely a benign cyst, it's something of concern.
Howard: Let's go from your fingertips to your eyeballs. When you're looking in the mouth, what are you looking for? What concerns you?
Lauren: Things in the mouth don't really come in that many colors. They can be blue, they can be red, they can be white. Pretty much it right. If it's an ulcer that looks like it does not heal and the patient says that it has not healed for a while then that's of course something to be of concern. Granted a lot times you can have an ulcer in the mouth and that can be a lot of things. If it's a non-healing ulcer, that's something to be concerned of. If it's more white than red or if it's mostly white, that's less concerning than if it's red.
I think the statistic of [lugoplatic 00:09:39] lesions 85% are just benign keratosis. That means they have a good shot at that being nothing. If it's red, if it's like [inaudible 00:09:50] it has almost a 100% chance of showing some sort or dysplasia, so that's something that's more concerning.
Howard: White is better than red?
Lauren: Yes. It could be white and red but yes. Just white is not as bad as red, exactly.
Howard: Basically the American flag, red, white and blue is pretty much could be all bad. Maybe the American flag needs [vouching 00:10:16]. When something suspicious, sometimes you hear people saying that the way that dentist did the biopsy, he messed up the diagnosis. Sometimes you hear oral surgeons complaining I wish I could have done the biopsy instead of you. Is that territorial turf protection or is that legit? If a dentist see something bizarre should they biopsy it and send it into a lab or do you think they should send it to an Oral Maxillo Facial Surgeon to do the biopsy?
Lauren: I think if they feel comfortable doing the biopsy there's no reason that they can't do the biopsy. If they don't have a lot of experience doing the biopsy then they might want to send it out to someone that does it more regularly.
Howard: Talk about what you like to see in a biopsy. Do you like to cut out the entire lesion?
Lauren: It depends on how big it is. Always take a picture first no matter what of the patient - I mean of the lesion before you cut it and then it depends. If it looks like it's something small enough where you can take the whole thing out then that's great. Otherwise, if it's too big make sure you also get normal margins so that the pathologist has enough to compare it to.
Howard: Okay, and what is the average size of a lesion when you see these and there bad by times it shows up?
Lauren: That's a good question. I don't really see patients before they're diagnosed. By time I'm seeing the patient and they've already had cancer. A few times I'm seeing them before the cancers been treated but a lot of times I see them and part of it already been excised. I think about the last patient I saw who had cancer on his palate I want to say, did he had an ulcer on his palate that was I don't know, maybe two centimeters in diameter which is really ...
Howard: Yeah. HPV is the big buzz word now in all cancer. Educate us on HPV.
Lauren: The thing with HPV is there are so many strands that just because you've been exposed to HPV doesn't mean that you have an increase risk of getting cancer. I think it's important to know that it's only the higher numbers, 16, 18, 32. That most people that are exposed to the virus actually clear it. It's really only I believe one percent of people that are exposed to it that don't clear it that are at that increased risk. Right now, I think we've been seeing HPV related cancers more commonly in younger males that don't have a history of smoking and drinking.
Howard: Why do you think it's males instead of females?
Lauren: The thought process is that it's related to oral sex and that the vagina can't clear the infection as well. I think that's what the theories are right now , weather or not that's true.
Howard: Males get it more because when they're doing oral sex on a partner that the vagina is more likely to have it in there because the vaginas not clearing it as well.
Lauren: Right, that's the thought. I think that's the recent theory right now. Whether or not that's true.
Howard: We hear the HPV vaccines, like I have four boys, they're 20, 22, 24, 26 ...
Lauren: I think so, yeah.
Howard: What strains is the HPV vaccine good for? I have the Hepatitis B vaccine. I think that's the only Hepatitis vaccine. There's not one for A, C and D, is there?
Lauren: There is one for A.
Howard: There is one for A?
Lauren: It's like newly developed. I mean not that new but like newer since you were born. I want to say like late '80s early '90s.
Howard: I was born two days before Fred Flintstones. You think my boys, 20, 22, 24, 26, they should get the HPV vaccine?
Lauren: Yeah, I think what the CDC recommends is that you should really get the HPV vaccine before you're sexually active so they're suggesting it in children as young as nine. If they haven't yet been exposed then, I don't think that there would be a reason not to get the vaccine. I would advocate for everybody to get the vaccine.
Howard: For your average 40-year-old American, what would the chance that the vaccine wouldn't be significant because they've already been exposed to what the HPV vaccine prevents you from?
Lauren: I don't know. I think probably like infectious disease control people would probably say it's a waste because they've most likely been exposed. I guess you could take blood and see if there are antibodies to it.
Howard: For my listeners. They're dentist, they're exposed to blood all the time. Do you think they should get this new hepatitis A vaccine?
Lauren: Yeah. Hepatitis is more fecal oral. It's more concerning if you're going and eating in like a developing nation where you're concerned about the food or if you're maybe ethnic food and they're not washing their hands well, I don't know, something random like that. If you're traveling abroad somewhere and you're concerned, I don't think it's as concerning as a dental office.
Howard: What if your dental office staff eats at Taco Bell?
Lauren: Then maybe you should be concerned.
Howard: I thought that was funny when I forgot the exact number when someone said you know it's not beef because beef has got to be, it's not all beef and they come back with, "Oh yeah it's like 30 some percent beef." I mean it's like, it was not the response I was looking for.
I don't feel like I'm smart enough to ask you. I almost think like you should go to a lecture because you're elite in this. What is dental oncology? What should my listeners be thinking about. Just take the floor. Take it away.
Lauren: Okay, so basically dental Oncology is the treating the oral and dental manifestations of cancer therapy. I did a fellowship at Sloan Kettering and what I did in the fellowship, it wasn't just looking at people suffering from oral cancer but it was really seeing patients before they underwent chemotherapy, before they received a stem cell transplant or before they were receiving anti-resority medication or anti-androgenic medications. Some sort of medications that may result in osteonecrosis of the jaw. It's really a combo of that. Of course seeing patients that were undergoing head and neck radiation and/or surgery.
Howard: When someone is being treated for oral cancer and we get them ... Sometimes we get patients, say this person is going to get treated for cancer. Fix them up first and then we get people back from being treated for cancer and they've got dry mouth. Talk about when an oncologist send you a letter and says, "Lauren is going to be treated for patients, I need her dentally taken care of by this date or versus the lady that comes back that had radiation on her head and neck, she's got all dry." Can you talk about those?
Lauren: Sure. Okay so if a patient comes to me before they undergo cancer therapy, let's say before they're undergoing radiation treatment, head and neck radiation treatment. First thing you do is of course you do a thorough exam. Take a through history. You're pretty much beefing them up before their radiation treatment. A lot of oral hygiene instruction heavy discussion with them about the risk of developing osteoradionecrosisof the jaw and the field of radiation and explaining to them that if they need teeth extracted now is the time to do it.
After they're getting that high dose radiation therapy, you're not going to be wanting to perform extractions in the field where the radiation ...
Howard: Is that for the rest of their life?
Lauren: I like to say for the rest of their life. I think it's also important to remember and I also explain to patients that radiation is, it is a beam it goes through. Even if the cancer is on the right side, if it's to the right back side base of tongue for example, you have to remember that the radiation goes through so the left back posterior teeth are also going to maybe be affected. Those teeth should also not be extracted because the beam went through and touched those teeth. After you do that and you take out the teeth appropriately and clean them up. I also suggest doing a prophylaxis before.
The next thing is to look in their mouth and see if they have a lot of metal restorations. If the have amalgams, PFM's that sort of thing, then you would make something called the radiation mouth guard which is preventing the back scatter from the radiation.
Howard: Wow, you're almost making a case for the future generations for the dentist to go metal-free.
Lauren: No, I wouldn't say take them out. I would just say. I mean I don't love amalgam but that's irrelevant. You're not going to be doing like a full mouth rehab because they have cancer and they've got to get it. Basically what you're just saying is if they have metal restorations, they're intact, there's nothing wrong with them, you just need to make a mouth guard that protects the radiation. We don't even really know how accurate this whole back scatter is but the thought process is that the radiation hits the metal and scatters and may produce mouth sores.
Howard: How does a dentist make this mouth guard?
Lauren: It's pretty much like a [inaudible 00:20:15] for me. It's like a night guard. It's soft. It's very thick. If I had one on me I would show you. It's just a very thick, clear thermoplastic material.
Howard: A thick, clear. What is it doing? It's helping the radiation not hit the amalgams and PFMs?
Lauren: Yes, the thought process is that it's kind of like a radiator cover so that when the radiation touches it, mostly it won't hit the metal and bounce off and the scatter on to the mucosa and cause mouth sores.
Howard: What is it made out of? The same stuff we make in [Aygar 00:20:49]?
Lauren: Yeah, no, no, no it's the same stuff. Just very thick.
Lauren: The thickest you can find pretty much.
Howard: I'm really hoping you make ... This is so important with an American dying every hour. I really hope someday you make this an online e-course.
Lauren: That's a great idea.
Howard: That we can play and the staffing, to the dentist, to the hygienist to get the whole team on board about you know. I can't believe there's not even this much media coverage about this. It seems like there's a lot of it in the United Kingdom. It's a much bigger story in the U.K where they're calling it mouth cancer.
Lauren: Right. It's a much bigger story for some reason in Europe in general. I don't know the U.S is a little behind the times with this for some reason.
Howard: By the way back to the doctor stuff. The dentist are always saying sometimes Americans will say, "Oh you're a dentist, you're not a real doctor." The dentist are sensitive to that and they'll say, "I am a doctor." I have to ask themselves are they really a doctor if-, when geriatric people come in your office and you don't even give them a flu shot but I can go to Walgreens and CVC and a pharmacy tech will give me a flu shot. Shouldn't the dentist be giving an HPV vaccine or discussing to mom, "Hey your daughter is-, your children are pre-sexually active," which in Arizona would probably be 16, in Kansas it'd probably be 12 and that was a joke.
Lauren: I know.
Howard: If we're real doctors and the average American sees a dentist twice every time they see a physician, shouldn't we be giving flu shots and HPV vaccines?
Lauren: Absolutely. I mean, I think that would be a great idea.
Howard: Why don't dentist demand the right to have the same right as the pharmacy tech at Walgreens? When you go to Walgreens to get a flu shot the pharmacist doesn't do that.
Lauren: No, you're right.
Howard: It's the tech. The tech didn't go, the cashier didn't do to school but the pharmacy tech went to school. I just don't get it why we're not the leaders in flu shots and HPV vaccines.
Lauren: Absolutely, especially 'cause they're intramuscular. The injection technique in comparison to a dental injection technique I think is much more straight forward. I mean what anatomy are they hitting when they ... right, it's true.
Howard: Where is the HPV vaccine and the flu shot vaccine given? In the arm, in the deltoid?
Howard: I mean it'd be pretty simple.
Lauren: Yeah, I think so. I don't think it would be very complicated.
Howard: I think Tennessee is the first state that is leading this issue on dentist should be giving HPV vaccines and flu shots. Tennessee.
Howard: They invented Jack Daniels and now they'll be the first to come up with a flu shot. Dentist have to demand that. I think it's time for dentist to decide are you just a high tech lab man because now they've got their Serac machine and they're scanning and milling. Are you just a glorified lab tech or are you a real doctor? Are you a doctor of the mouth? Are you a physician of the mouth? Are you a stomatologist? Like in Russia and the Ukraine which is really when it comes to dentistry advanced, far more advanced than us.
Howard: What else do you want to talk about? What would be the best use of your time right now with my listeners talking about your specialty. Oh by the way when you said Sloan Kettering, congratulations on that, that's one of the top four most elite cancer hospitals and I just think Sloan Kettering, I think of male clinic I think of the Houston. Sloan, someone I don't mind, Alfred Sloan was the founder of GM. Henry Ford had the whole market with one car. You could have any color you wanted as long as it's black, and it was actually Alfred Sloan that came in and offered price segmentation and said, "You know Henry's got one car but what if you don't want just the 668 dollar car, what if you want to pay a little ... We'll have the Chevy compete against that. Or we'll pay a little bit more with the Pontiac and we'll have the wheels come off and we'll have a little more money for the old mobile and it'll have a roof over it."
We'll have a little more money and we'll have an automatic starter deal so you don't have to go out there and wind it up. The Cadillac had a roof, removable wheels, an electric starter deal and the craziest thing that they ever did. A little company called Motorola was making a radio for a car and Henry ford laughed at Alfred Sloan and GM ended up slaughtering the Ford. He closed down his assembly line and he donated a huge bunch of money for the Alfred Sloan Kettering but whose the Kettering guy? I'm embarrassed that I don't know the story of that founder.
Lauren: I don't even know the story that you just told so I don't know.
Howard: Oh my gosh, you went all the way through the Sloan school and you didn't know the story of Alfred Sloan. I'm telling you it would be a crime against humanity if you went through his foundation and didn't read my years at GM by Alfred Sloan. It is just a walk through economics. Then when you do our online course you're going to have to have an opening. Tell us who the Kettering guy was.
Howard: Or email me his first name and last name so I can look it up because obviously he had a ton of money and he was a good guy and living it for cancer. What else do you think you learned in your training that the general dentist like me doesn't know and should and should think about?
Lauren: I think one thing that initially when I was there I didn't think of but now it always comes to mind is if a patient tells you they have breast cancer or prostate cancer, always ask them, is it metastatic and if so did it metastasize the bone? Because if it's metastatic and metastasize the bone they're most like going to be on a [disfosfonate 00:26:47] or Denosumab. As we know both of those drugs, well I guess [disfosfonate 00:26:54] is a group of drugs but those anti-drugs or medications are associated with osteonecrosis of the jaw.
Howard: Explain you said [disfosfonate 00:27:03]?
Lauren: Right, [disfosfonate 00:27:05]
Howard: That's the generic name. Are there any brand names?
Lauren: Yeah so, [disfosfonate 00:27:10] are those huge, that giant drugs that includes Boniva, Fosamax, Aredia Medronate is the generic name. Actonel is another one. Some of them are oral, some of them are IV. A lot of the US population are on them orally for osteoprosis or osteopenia but what's more concerning are patients that are on them IV and have a history of cancer or being treated for metastatic disease to bone or multiple myeloma.
Howard: What was the other one?
Lauren: Denosumab. Which the training for that is Xgeva or Prolia. Prolia is for osteoporosis. Xgeva is the one for cancer usually.
Howard: If a patient is on those drugs. What red flags pop up? The dentist should not be doing any extractions. Talk about what changes?
Lauren: No extractions, no implants obviously. No boney surgeries. Be careful if you're doing even cleaning. You don't want to be disrupting the bone because they're at risk of getting this osteonecrosis of the jaw, of the area not healing properly. I think it's really important to also tell patients the minute they tell you that they're on that you have to explain to patients that they have to be careful not to get invasive dental procedures done.
Howard: What if someone comes in and they're on that and that have to have an extraction. I mean it's easy for me. I'm in Phoenix. I just dump it on my oral surgeon. I don't even want to deal with this. What if you're the poor bastard oral surgeon?
Lauren: I wouldn't extract it. I would say that the tooth can get a root canal and you can get a coronectomy and then you just seal it off to the gum line. I would not recommend extracting the tooth.
Howard: If they're just on the drug or if they're on the drug and have cancer? If they're just on the drug?
Lauren: It depends on how long they're on the drug for. Osteonecrosis of the jaw is more commonly associated with IV, 96% of ... Here's the annoying thing about this. The incidents of osteonecrosis of the jaw is very low. You obviously have to tell your patients and let them make the informed decision. There is a chance of getting it unfortunately and the chance is higher if the drugs are IV. If the patients that has several doses of it and they're still maybe being treated or even if they're not being treated, they've had several doses the half life of [desfosfonate 00:29:42] is 10 years.
Lauren: The likely hood that it's in their system is high. It probably is still in their system.
Howard: Did you just say 96% of the people that did get Osteonecrosis have this [desfosfonate 00:29:53] delivered to IV?
Howard: When they get an IV, how long is the IV in? They go to the doctor and they put them on an IV of this stuff?
Lauren: They go in, they get IV, they leave, they come back, they go in and they get it. It's not like their, yeah.
Howard: Explain to the viewers, what does that mean. Let's say someone did IV [desfosfonate 00:30:13]. They pull the tooth, they got osteonecrosis. What is Osteonecrosis? Why is this bad? I'm sure most everyone has never seen a case. What does it mean, your jaws going to die?
Lauren: It's basically exposed bone in the maximal or the mandible. It's more common in the mandible because you know that limited blood supply. Sometimes you can just see an ulceration. Usually you see exposed bones. Sometimes that can lead to separation associated with the area. The real concern is that it can lead to jaw fracture that if it propagates ... That's the major concern and then of course infection.
Howard: Do you get patients like this? Have you seen patients like that?
Lauren: Yeah. I have unfortunately.
Howard: What do you do for them?
Lauren: To be honest there's really not that much to do. It's just palate of wound care. If it looks like it's an infectious process and there's separation you prescribe them an antibiotic. The concern with the antibiotic is that sometimes it can't penetrate because there's no blood supply getting to the area so the antibiotic cannot get delivered. I always prescribe them Chlorhexidine gluconate, I do it alcohol-free. Tell them to keep the area extremely clean. You keep the area extremely clean and just kind of watch it. The hope is that the bone will just exfoliate and the general will just fossilize over.
Howard: What if your patient is Irish like me and they can't drink anything without alcohol in it?
Lauren: I mean I guess you could use the chlorhexidine with alcohol if you really ...
Howard: Okay, good point. You're giving me faith. This oral cancer exam with HPV a side effect we used to think an oral cancer exam on grandpa and grandma. Especially if they checked yes, I smoke. Who should be given oral cancer exams now?
Lauren: Everybody. I would say no one's excluded from that.
Howard: At any age?
Lauren: Yeah, absolutely. You never know. When you're doing the oral cancer exam. You're just looking for everything it might not be ... You don't know what you're going to find so it doesn't take a very long time to do that exam.
Howard: Is oral cancer different if it's caused by smoking, drinking, versus HPV as far as location of mouth? Is HPV more back of the throat, oral foringio, and smoking drinking more interior lip, tongue?
Lauren: The most common site for oral cancer is still the lateral boarders of the tongue, followed by the floor of the mouth, then you or those ring area. I guess if you're doing snuff it would be a good place to look but also be where they're keeping the snuff. Lateral boarder of the tongue is still the number one spot of cancer.
Howard: Lateral boarder of the tongue could be from HPV or smoking and drinking? Are you saying that HPV induced all cancer doesn't really so much change the location of the cancer?
Lauren: I guess there all kind of in the back area, so no.
Howard: I've heard some dentist believe that HPV is more [crosstalk 00:33:42], back of the throat as opposed to smoking and drinking more lateral boarders of the tongue.
Lauren: I think that is true. If it's HPV related, you more likely see it there. I think statistically is that the number one spot for cancer in general of the mouth is lateral boarder of the tongue if that makes sense.
Howard: I know a lot of people that I'd like to prophylactically remove their tongues so that they don't ever get oral cancer. I'm at 34 minutes here. I've only got 25 minutes left. Like I say, I don't feel like I'm smart enough to ask you the questions, I almost like it should have been just a lecture. What else did you learn after all your years of [chasing thing 00:34:25] that you don't think you knew when you were in dental school? What do you think you know that a general dentist doesn't know that they should be thinking?
Lauren: What should they be thinking? Okay, so we went over the drugs for people to ask about because that's very important. A take home message maybe you're saying?
Howard: No. What else do you want to talk about?
Lauren: What do you think is the most beneficial? Talk about maybe treatment options or ...?
Howard: Sure, whatever you think.
Lauren: Lately I've been seeing a lot of people that actually have Graft-versus-host disease in the mouth. Basically I see patients before they undergo transplants as well as after transplants and if you have Graft-versus-host disease in the mouth it's of course after they're getting a stem cell transplant. Basically it kind of looks like timpanist. It's white, it has a picket like fence. It can be on the tongue. It can be on movable mucosa anywhere. The first thing to do is obviously to diagnosis it. What you do is you take a biopsy of minor cells event in the lower lip.
The conversation goes like this, the oncologist might send you a patient and say, "I see something in the patient's mouth I don't know what it is," send them to you, you take a detailed history of the patient find out that they had a transplant, take a biopsy of the lower lip or I guess the oral surgeon can do it. Somebody took a biopsy of the lower lip find out if GVHD.
Howard: Find out it's what G?
Lauren: GVHD, so Graft-versus-host-disease.
Howard: Oh Graft-versus-host disease, GVHD. Graft versus host disease. Explain what that means. Graft ...
Lauren: Basically it means that the graft is attacking the host. They either got a transplant from somebody else.
Howard: What's the most common, a kidney? What are the transplant these days?
Lauren: I'm talking about stem cell transplant. You definitely can get this from a solid organ transplant, but I don't really see so many patients from solid organ.
Howard: You're calling a stem cell treatment for cancer is actually a graft. It's from someone else.
Howard: See I never even thought about this, that's why I'm saying I'm not smart enough to ask you questions. Stem cell treatments Graft-versus-host disease is now ...
Lauren: Exactly, here's a summary of what happened. A lot of patients who have a history of leukemia or lymphoma might be treated with a stem cell transplant. They undergo high dose chemotherapy. First the oncologist will harvest the cells. I guess that's not really fair it depends. You can have a stem cell transplant from yourself or you can have it from somebody else.
If you have it from yourself they'll take out the cells first. If you have it from somebody else essential transplant is a broad term for something like a bone marrow transplant. That might be a version of that. Basically what they do is a white your body ... you undergo high dose chemo, total body irradiation and so this way the body can accept these new cells that are not filled with cancer. If you have Graft-versus-host disease for whatever reason unfortunately the graft is actually attacking the body.
Howard: If you have Graft-versus-host disease just think GV black GVHD, there can be oral manifestations from that.
Lauren: Yes, in fact a lot of the times oral manifestations might be the first manifestation.
Howard: Okay, so then talk about that. What are these oral manifestations and how do you treat them?
Lauren: Dry mouth these picket like fences, ulcers in the mouth, sometimes even trismus. Feelings of the muscle tightness and being fibrotic. It's actually a pretty big deal because if it's localized to the mouth that's okay, but if it's localized to the mouth and it's going to become systemic, Graft-versus-host disease can actually be life-threatening. You don't want to take this with a grain of salt. You want to treat it appropriately. You can treat it with dexamethasone rinse. I like to do it with Orabase.
Howard: Slow down and say those again. Dexamethasone rinse.
Howard: You call your pharmacist and tell them that or is there a brand name?
Lauren: It would be dexamethasone .1% mouth rinse. The concern with that though is that it is a steroid so you don't want them to be swallowing that. My first line of defense usually is Temovate with Orabase.
Howard: Temovate with the Orabase?
Howard: Spell it.
Howard: I'm trying to figure out your accent. Where, you went to Florida ...
Lauren: New York.
Howard: You're a New Yorker?
Howard: Born and raised in New York?
Lauren: Yes, born and raised in new York.
Howard: Which part? Manhattan, Brooklyn, Bronx?
Lauren: I live in Manhattan now but I'm from Long Island.
Howard: Okay, spell that.
Howard: How is that different from dexamethasone?
Lauren: Dexamethasone is a mouth rinse. The Temovate is a cream.
Howard: Oh okay.
Lauren: You have them and it's with Orabase so that it sticks on better because otherwise the cream you just need to put it in the mouth and it's going to go everywhere, but if it's with Orabase is kind of, you tell the pharmacist to make it this way. Then you tell them to apply it to whatever lesions they have in their mouth.
Howard: Would a standard pharmacist at Walgreen's or CVC do this or do you need like a special ...?
Lauren: No, they will. Yeah, they will. You sometimes have to call the pharmacist and make sure that they'll mix them for you. It's usually not a big deal.
Howard: What are the individual pharmacist called? Hyper ...
Lauren: I know what you're talking about.
Howard: Hypothecaries. All they do is the stuff that the big change that really don't really do.
Lauren: Right, but I've never had that problem so far, I mean because you can also just tell pharmacist to order things. Like sometimes I will prescribe random things to patients and you just have them order it. Like the chlorhexidine believe it or not alcohol-free chlorhexidine gluconate is like a big, it's not so easy to find, so you just have to push them and say no it actually does exist. It's a purple formula.
Howard: Now that you said that alcohol-free let me tell you an old school debate probably before you were born. I don't want to know what year your were born. I don't want to ruin the rest of my day. When I got out of school in 87 a lot of people didn't like alcohol mouthwashes because they thought that caused oral cancer. Then there were other people say, "No, that when you're in alcohol it's what it's doing to your liver that's making cancerous stuff." Swishing with alcohol does not cause oral cancer. Drinking alcohol and having a broken down in your liver is what cause cancer is that true or false, what's the what do you say, current thought is?
Lauren: I think the current thought is that you shouldn't be swishing with alcohol. I don't think it's confirmed I don't know what the studies are saying about whether or not it could actually cause oral cancer, but if alcohol is related to cancer elsewhere why should you be switching your mouth or something that might be related to ... it could be causing cancer in your mouth.
Howard: Probably everybody wants to know since you're an oral oncologist what brand of cigarettes do you smoke and what type of wine and whiskey and beer do you drink?
Lauren: Very funny.
Howard: I take it that's a no across the board.
Lauren: I mean, I drink alcohol socially but I do not smoke cigarette. Never smoked cigarettes.
Howard: Do you think a social drinker like your drinking habits, do you think a social drinker a moderate drinker is that increase risk of oral cancer?
Lauren: It's tough to say because there are some benefits to drinking some amount of alcohol, right? There was a [inaudible 00:42:59] on red wine being proceeded with reduced risk of heart disease and that sort of thing. I don't know if there's really that many studies that clearly define that. I think that would be a really hard thing to tell because I don't know how they would do a study by that, if it was a survey with people really tell the truth about how much they drink? Probably not much.
Howard: I think the key to all that stuff is moderation.
Lauren: Yes, I agree.
Howard: I'm down to 15 minutes with you. What else can you educate all these dentist listening to you today on what you learned at Sloan Kettering that they probably might not know or should think about. I bet a lot of people are wondering right now just the human side of the story, what's a day like in your life? What do you do 8 to 5? Where do you work? Are you in a hospital, are you in a private dental office?
Lauren: I'm in a private dental office.
Howard: In Manhattan?
Lauren: In Manhattan. I mainly see patients that are referred to me from oncologist. I mean some people have found online but usually oncologist send many patients, a lot of these patients have a history of oral cancer and the radiation oncologist will refer the patients to me before they undergo radiation treatment. We'll do a thorough exam like I was saying before. Work them up, beef them up, and then I usually I take measurements of them as well as the baseline because as we know radiation therapy can cause xerostomia and hypersalivation, because it affects the salivary glands.
Howard: Is that for the rest of their life? Is that for daily potential?
Lauren: It depends on the extent of how much radiation therapy. If they're getting head and neck radiation therapy and it's going to be above 25 gray, the results will be irreversible. They might get some salivary flow back but it would probably won't be the same as it used to be.
Howard: Above 25 grey?
Howard: What does that mean in English?
Lauren: Gray is just the way of measuring radiation.
Howard: What if one of my listeners wants to ask you a question are you up for that?
Lauren: Yeah, absolutely.
Howard: How would they ask you a question? How could they contact you? What's your preferred method? Do they go to your website LaurenleviMD.com. Which is L-A-U-R-E-N Levi, L-E-V-I, DMD.com? How they contact you?
Lauren: Yeah, that's great.
Howard: Or do you prefer email or phone?
Lauren: Yeah, they can email me. It's drLaurenlevi@gmail.com. It's Dr, Lauren Levi at gmail.com so no period anyway, I guess.
Howard: You're in Manhattan. Do you think you'll ever grace us with the privilege of getting the online [crosstalk 00:45:50]
Lauren: Yeah, that'd be great.
Howard: We would absolutely love it. The story just gets bigger by the day.
Lauren: Yeah, absolutely.
Howard: Do you think it's confusing around the world on the Internet where the Brits are calling it mouth cancer and we are calling it oral cancer? Why do they call it mouth Cancer and we call of oral cancer? What do you prefer to call it. Mouth cancer or oral cancer?
Lauren: The question is which word do you think encompasses more oral or mouth? What do you think, I don't know. What do you think, do you think oral sounds more general than mouth? I think it might.
Howard: When I think of the 7 billion people they might know mouth more than oral.
Lauren: That's true actually, so then maybe mouth is a better term. I guess my only thought process is that oral might encompass the oropharynx, the truth but I guess that people are maybe thinking, people think of the throat more associated with the mouth.
Howard: The other human element side of the story, people are wondering is how the heck did you get out of dental school and end up in oral oncology? Explain that journey. How did you get from doing fillings, crowns, and root canals to oral cancer?
Lauren: That's a good question.
Howard: Was that taking a much more harder road for yourself, I mean you're dealing with life and death. It seems like a much more stressful job then somebody that goes in the office that does fillings and crowns all day.
Lauren: It's definitely very different but I feel like it's really rewarding. I always liked the oral pathology and oral medicine in dental school. What I felt like was missing, it's not fair for me to say what I feel like was missing, what my concern was, is like I was worried that if I went down one of those routes that I would have be seeing patients that much and doing dentistry that much. Like the actual filings and crowns. What's nice about dental oncology is it's really a fusion of both.
That there is a lot of oral medicine and oral pathology associated, but you are still restoring people's mouths and getting them ready and seeing them after their treatment, during their treatment and doing conventional dentistry, so it's a nice fusion. I did a residency at Cornell and at Cornell you rotate through Sloan Kettering and that's how I stumbled upon this.
Howard: The other thing we haven't talked about any is oral radiology. When I got out of school, it was pano. I'm so old that when I got out of school the biggest invention on oral radiology was someone who put a, figured out how to put L on one side of the pano and R on the other. We just thought that was just, wow. That was a great idea. Now we have hundred thousand dollar CVCTs. Is that part of an oral cancer exam. Are CVCTs going to be a game changer for oral cancer or is that more ... or is oral cancer really more of the soft tissue and not really boney lesions and we're not going to be ... Are we going to be detecting more oral cancer because we have three dimensional CVCTs or not really is it mostly still a soft tissue disease?
Lauren: It's still a soft tissue but I wouldn't discount it being in the bone, so I think yeah, as technology gets better with imaging, the more information that we can take the better. Again, when people think of oral cancer they're not thinking of the boney manifestations but absolutely. That's not something that should be ruled out.
Howard: What percent of oral cancers would have a boney manifestation?
Lauren: I think it's more concerning that it be metastatic disease to the jaw first then it being oral cancer that first started in the jaw, if that makes sense. A met from breast cancer or prostate cancer going to the mandible. That's not to say that oral cancer can not manifest in the jaw, unfortunately, germi-carcinoma can manifest in the jaw. We know that there's a bunch of different cancers that unfortunately fall [inaudible 00:50:04] also.
Howard: Now let's switch to the ugly part of the interview. When you see this space oral cancer, what is their life expectancy? Are you just helping these people live a little more comfortable for the last year of their life. Are they getting two years, three years? Do they ever get cured? What's it like on the dark side?
Lauren: On the dark side I think it's pretty good. I mean obviously every patient is different but a lot of the times I think I'm seeing patients that, as long as you're seeing patients that are diagnosed early enough. The survival rate is actually pretty high. It's when you catch it too late that's when the concern is. If you catch it early and they're being treated then that's pretty good.
Howard: It seems like, I'm the dentist, I'm not an oncologist but it seems like whenever you read about cancer it's basically always four stages. Is that the standard deal? Like on a Google ratings it's five stars. Cancers 1,2,3,4.
Howard: Walk us through the survival of oral cancer of stage 1,2,3,4? If you pick it up stage one is it like going to be a very high chance living in stage four, like no chance you'll live?
Lauren: I don't think it's no chance but I think it drops to being like 50% if you're going to stage 3 and stage 4. I think if you're catching it early then like I was saying then the survival rate is significantly higher.
Howard: How come we always see articles in the press that say oral cancer seen no increase in survivability since it was first discovered in like 1950. The problem with the internet is you've got to figure at least 90% of all the stuff you read on the internet has got to be crazy.
I try to stick with trusted sources. That's another great question. What is a trusted source? Is WebMD, what are good websites for dentist to be learning about dental oncology?
Lauren: The NIH has a really good review of basically like the dentist role on cancer treatment and if you see a patient before stem cell transplant and what to do if you see your patient before had a neck radiation chemotherapy what to do and it's very detailed. I think that's great.
Lauren: I don't know ... it probably dot.gov. [crosstalk 00:52:31] ...
Howard: Is that the same as pubmed.com? Or PubMed. Is NIH the same as PubMed?
Lauren: Is that the same thing? I don't know. I don't think so. Basically if you type into Google like cancer, dentist, NIH it'll come up. Then there's another one like the NIDCR is pretty good as well. That's more of a dental website.
Howard: NIDCR, is that what you said? NIDCR?
Howard: National Institute of Dental and Craniofacial Research?
Lauren: Yes, yes. That's exactly it. That one is great as well. I think I would take those two. I also really like up to date, but you have to have a subscription to that.
Howard: How much is a subscription to that? You don't know.
Lauren: I don't know, but that one is great. If you have institutional access or something, it's free. Most hospitals have up to date, it's great.
Howard: How rare are you? How many dental oncologist are there in the United States? Do you guys have a national association?
Lauren: We don't. It's a pretty small niche and I think not that many people know about it, I don't know. Sloan Kettering has a program and the Anderson has a program.
Howard: MD Anderson, that's Houston?
Howard: MD Anderson is Houston. Sloan Kettering is New York. Mayo is Rochester.
Lauren: Right. I don't know if Mayo has a program.
Howard: That's about the only three people, the rich and elite people from around the world go to for cancer isn't it? Just those 3?
Lauren: Yeah, I guess so.
Howard: I mean if you've got all the money in China and you get a bad case you're going to go to one of those three hospitals.
Lauren: That's correct.
Howard: In fact, I've lectured in 50 countries and the same goes in every country if you get cancer you don't need a doctor, you need a pilot to fly to America. Then when you get there stop at either Sloan [crosstalk 00:54:24] ...
Lauren: That's true.
Howard: I've heard dentist say that to me so many times.
Lauren: Yeah, I agree.
Howard: That must be a fun group of people you're hanging with.
Lauren: Yeah, no, I mean I think it's really a much more upbeat field that it probably sounds like. I think you just have to have the right mindset. What's great about it is that it's a very rewarding and it really makes you appreciate life. Like who cares that you woke up on the wrong side of the bed. The patient you just saw is battling cancer and like he's happy so you better like shut up and not complain that you spilled coffee on yourself. Something like that. It really makes you put everything into perspective.
Howard: That must be very rewarding.
Lauren: Yeah, it really is.
Howard: For me, every dental missionary trip, I remember the very first time I did my first missionary trip it was in Chelpus, Mexico. When I was flying down there and doing all this paper work and I'm going a million miles an hour. I thought I had all these problems with my business and raising for kids and then you get down there and see five thousand people living with no electricity and you're just like, "Okay, maybe I don't have a problem."
Howard: Maybe you, every patient you see you're sitting there thinking, "Wow, I'm having a much better day than I might think I'm having."
Howard: How many dental oncologist do you think there are?
Lauren: Well the program at Sloan, there's four fellows every year. I'm not sure when it was founded but I want to say it's been around for at least 20 years. They're producing four. Probably more than 20 years. I don't know 30, I don't know how long it's been around. I don't really know the history of the others but I think that also has four fellows.
Howard: Four every year or just four period?
Lauren: Four every year.
Howard: Four every year. For a country of a third of a billion people.
Lauren: There's probably more. I'm sure there are other programs that I don't know about. I think there are a few other programs that spreading. I think there's a program in Buffalo that's just opens. When I Googled to look for other programs, it looks like, I did recently. I also have this question because we don't have an association or anything. If patients are looking for somebody that has dental oncology background and a lot of states it's not so easy to find them.
Howard: If you want me to, I've got 50 employees. If you want me to create an association for you, I mean build up a website or whatever I'll absolutely do it because it's just that important.
Lauren: Yeah, no it really is.
Howard: If you want me to do that, I'd be glad too because, or oral cancer it just seems to ... it's the most serious thing in dentistry and it's ...
Howard: The fact that we're 99% everything you want to read about dentistry so it's going to be a cosmetic veneer case on some beautiful person like yourself, and then 99% of dentistry is not veneer as in bleaching and bonding and all that stuff. Then here in your area, people are dying. So as soon as we imburse relationship between importance and press coverage.
Lauren: Absolutely, no I can ...
Howard: Who was the football player? Was it Jim Kelly or who's the famous buffalo ...?
Lauren: I think that's, it was Jim Kelly wasn't it?
Howard: Yeah, I think so.
Lauren: I think so, too.
Howard: Have you heard anything about his case? Is he dentist, BFAD ...
Lauren: I don't know.
Howard: You don't know. Yeah, HIPAA probably wouldn't allow us to say.
Howard: Anyway, so I just want to say seriously I think you're a rock star, I'm a huge fan of your website, I'm a huge fan of you period. I think what you do is unbelievable. I really hope we put up about I think 327 courses on, then all time they've been viewed over a half million times, and all 206 countries. I think the world needs to see some online. I hope you put it off ...
Howard: Thank you so much for taking an hour of your important world and spending it with me. Thank you for all that you do for dentistry and thank you for all you do for your patients. It was just an honor interviewing you today.
Lauren: Thanks. No, it was great. I'm really glad I did this. Thanks so much and I love dental them.
Howard: Oh, thank you very much. All right. Talk to you later.
Lauren: Okay. Bye bye.
Howard: Bye bye.