Dental specialist repairs damage to mouth, head, neck

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Oral cancers account for about 3% of cancers diagnosed each year in the United States. I'm speaking today with Dr. Arthur Bigsby. He's a maxillofacial prosthodontist, which is one of the specialists who may be involved in the care of patients with oral cancer or head and neck cancer. He's also a member of the Upstate Dental Clinic faculty.

Welcome to "The Informed Patient," Dr. Bigsby.

Arthur Bigsby, DDS: Thanks, Amber. I'm excited to be here. This is a pretty cool opportunity.

Host Amber Smith: Well, I'd like to understand the role of a maxillofacial prosthodontist, and I may not be saying that right. Does the training start with dental school?

Arthur Bigsby, DDS: Yeah. Dental school's similar to medical school. It comes after college. So there's an entry exam, you get into dental school, dental school's four years, and then, specialty training to become a maxillofacial prosthodontist takes between four and five years. For me, it was a five-year journey, so I left SUNY Buffalo, where I did dental school, and I came to Upstate, actually, and did a one-year general practice residency, where you're exposed to sort of the whole gambit of dentistry, doing extractions, fillings, hygiene checks, the normal stuff you'd see your dentist for.

And then I did three years of training in prosthodontics, which was down at the Manhattan VA (Veterans Affairs Hospital) in New York City. And so that's specializing in prosthodontics, which is a specialty in dentistry and focuses on veneers and crowns and bridges and dentures.

And so that's sort of what you think of when you see someone in Hollywood that has a beautiful white smile. Or when someone has a really broken-down mouth, fixing that. That's prosthodontics.

And then after the Manhattan VA, I did a one-year fellowship at the Mayo Clinic. The program's referred to as maxillofacial prosthetics and dental oncology. So what that means is, I went out to the Mayo Clinic and focused specifically on cancer and congenital abnormalities and then just trauma to the head. And so basically a maxillofacial prosthodontist, to sum it up, fixes anything from the shoulders up, prosthetically.

So, if someone's missing an eye or an ear or a nose, we'll replace those. If someone has oral cancer and a portion of the throat or the mouth is removed, we'll replace that. And certainly we still have our previous training, where we do normal dental things like bridges and veneers.

Host Amber Smith: So how did you choose this field? Did you think that you wanted to be a dentist and just keep going?

Or did you, before you got started, did you think, this is what I want to do, and it's going to take this much time to get there?

Arthur Bigsby, DDS: That's an interesting question.

It's kind of a long answer, but I was interested in medicine as a kid, and a lot of my family's involved in dentistry here in Syracuse. The Fallons are oral surgeons in Syracuse who are my cousins and uncles, and so I used to shadow them, and I loved oral surgery, and, one day when I was shadowing them, they said, why don't you go shadow a doctor down the hallway, Dr. Leo Massaro? He's a maxillofacial prosthodontist.

And I remember the first thing I saw in his office was an impression of a patient who, for lack of a better term, half their face was missing. And so the patient had had a large oral cancer, and he was making them a prosthesis to replace their palate and their eye. I thought it was very interesting.

And so, kind of fast-forward, I was so interested in it, I would shadow him. He was really great to me. He was a fun guy. The work that he did was amazing because you weren't just treating the mouth, but you were treating a patient systemically, and you were involved in team care.

And so, through dental school I was always interested in this, and I kept pursuing it, and it worked out kind of step after step. And I just feel really fortunate and blessed to be where I am.

Host Amber Smith: So are most of the patients that you deal with, are they facing cancer or oral cancer?

Arthur Bigsby, DDS: I would say the majority of the patients for a maxillofacial prosthodontist, yeah, they are.

And so when I'm at Upstate, the majority of the patients either are starting treatment for oral cancer and oropharyngeal cancer, or they've had it. And so we're either prepping them for treatment, or they are responding to treatment, meaning we're making them a prosthesis to fill a void. I, in private practice, treat regular dental patients as well, but mainly at Upstate, it's cancer.

Host Amber Smith: Regarding oral cancers, are these typically discovered by dentists when a patient comes in for a routine cleaning?

Arthur Bigsby, DDS: They can be. Dentistry is a great way to screen for oral cancer and oropharyngeal cancer. If you think about it, ideally you see a dentist twice a year for cleanings, and so it's a great time for dentists to give you an oral cancer exam, which should include a palpation or feeling the neck up and down the neck, underneath the jaw, the joint, and then visually. And again, physically inspecting the mouth, not just the teeth, but looking at the soft tissue of the mouth and the throat and the tongue, just to confirm there's no irregularities that should be further examined.

And so, while I can't say exactly the statistics on who's diagnosing oral cancer, dentists do have a unique opportunity to see a patient very often and diagnose it if it's present.

Host Amber Smith: Are there symptoms that a patient might notice and bring to the attention of the dentist or their doctor?

Arthur Bigsby, DDS: Yeah, absolutely. You should never be ashamed to bring something up that feels weird. The big signs for oral cancer and oropharyngeal cancer are non-healing lesions. If you've got a lesion in your mouth that's unilateral, meaning it's on one side, and it's not on the other side, that's relatively unique, especially if that thing doesn't go away in, like, two weeks. So, if you notice something that is on one side of your mouth, and it either hurts, or it bleeds a little bit, especially if you feel it with your finger and that elicits some bleeding. Cancer is generally very vascular, so there's a lot of blood vessels in it because it's growing and turning over. So if you're able to rub it, and it hurts, and it causes bleeding, and that's going on for over two weeks, that's something to bring to the attention of your dentist.

The other thing that's weird to think about, but the most common oral cancer is actually lip cancer. So, if you've got a lesion on your lip, not like a cold sore, but if you've got a lesion on your lip that doesn't go away for over two weeks, and it's irritated and red and it's bleeding, that's something to bring up to a dermatologist or a dentist as well.

Host Amber Smith: So I didn't realize that, that lip is the most common area.

You said that, oral cancer could show up on the tongue or on the inside of the mouth or the throat anywhere, right?

Arthur Bigsby, DDS: Right.

Host Amber Smith: You used the term "oropharyngeal."

Arthur Bigsby, DDS: Right.

Host Amber Smith: What that mean?

Arthur Bigsby, DDS: That's saying, basically, if you think of the oral cavity and the throat as two separate things, oral, oral cavity, that's like the mouth, so the gums, the cheeks, the front of the tongue, the floor of the mouth. The pharynx is like the throat. So now you're talking about like the base of the tongue, the tonsils, the soft palate and the back of the throat. There's a lot of areas in there for cancer to grow.

So, again, when you asked about, like, what would you look for, something that people will miss is, like, tonsil cancer. So if you've got cancer in a tonsil, it looks swollen, and you think back to when you were a kid, and you had swollen tonsils, you're like, oh, this is just a swollen tonsil or strep throat or something.

Well, if it's growing from one side and not the other, and it's lasting over two weeks, that's something you should definitely bring to the attention of a physician. So, any one-sided irregularity should definitely be brought up to a physician.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with Dr. Arthur Bigsby. He's a maxillofacial prosthodontist and member of the Upstate faculty in the dental clinic.

What about head and neck cancers that are caused by HPV? We've heard about human papillomavirus causing more of these head and neck cancers. How are those typically discovered?

Arthur Bigsby, DDS: Just to touch on HPV: So, HPV is an epidemic that's going on right now. While I was in my fellowship (specialist training), the majority of the patients that I saw were diagnosed with HPV-positive or p16-positive, for just a quick way to say it, HPV-positive cancer, which means that it was regulated or caused by HPV.

And so, a person with HPV cancer sort of looks different than what we think of when we think of oral cancer. The classic oral cancer patient is over 40, tobacco smoker, alcohol drinker, or they chew tobacco, and they get cancer on their tongue or on their lip. Well, HPV, which is more the pharyngeal part that we were talking about earlier, the throat or the base of the tongue or the tonsils, it's cancer in those areas. Again, well, you'll notice a unilateral growth, or you'll notice, like, a pain or trouble speaking, like you might have, like, a frog in your throat or something, or maybe even like difficulty moving your jaw. Things like that.

Those are in the back of your throat. Those are usually signs that there might be something like cancer kind of brewing. And it's likely these days that it's HPV-positive cancer. The majority of the cancers in that region are now HPV-positive.

Host Amber Smith: Do you do a biopsy, do you sample the tissue to find out if it's cancerous?

Arthur Bigsby, DDS: Yeah. The definitive diagnostic exam for cancer is a tissue biopsy.

And that's not like a brush biopsy. A brush biopsy is used in some cases, sometimes appropriately, maybe not as appropriately as it should be, where you run, like, a swab over tissue to look for cancer. I wouldn't say that's the standard of care.

I'd say that a biopsy where tissue is removed and sent to a lab to be examined and diagnosed is the standard of care for diagnosing cancer. And unfortunately, most commonly in the mouth, it's squamous cell carcinoma. I think over 90% of oral and oropharyngeal cancers are squamous cell carcinomas.

Host Amber Smith: I realize that treatment will vary depending on the patient and the location of the cancer, but what might treatment include, and at what point would a maxillofacial prosthodontist become involved, either for oral cancers or for head and neck cancers?

Arthur Bigsby, DDS: That's a great question. There is some variety in the treatment modalities, depending on the diagnosis.

The treatment generally is chemotherapy and radiation and surgery, sort of lump chemotherapy and radiation together just broadly, and surgery is another option. And so those are usually used in conjunction. Some places will err on the side of one or the other, but generally surgery is done to remove cancer.

At the time of surgery, generally, lymph nodes are removed in the head and neck, adjacent to the cancer to make sure that the cancer hasn't spread along lymph nodes. If it has spread along lymph nodes, that changes the future treatment plan, which generally involves radiation or chemotherapy and radiation.

Chemotherapy is basically saying that we're going to use medicine to help kill the cancer or control the cells that are turning over too quickly. Now, you can also not do surgery, and you can just do chemotherapy and radiation.

We were talking about human papillomavirus earlier. The fortunate thing about HPV-positive cancers is, they have, like, an 85% to 90% survival rate at five years.

And so that's because they respond really well, meaning they die. the cancer does, when treated with chemotherapy and radiation. And so, usually, a curative course of treatment for oropharyngeal cancer that's HPV-positive is about seven weeks, going in to see your radiation oncology team daily to receive radiation directly at the area of cancer. It gets very complicated from there, the different ways that cancer treatment is delivered, the radiation types, but generally it takes about seven weeks.

And so where does a maxillofacial prosthodontist come in?

If we're on the team, we're usually involved in the initial meeting, not necessarily the diagnosis, the meeting. We don't take biopsies usually. Usually we'll send those to our surgical colleagues, whether it be an otolaryngologist, meaning an ENT (ear, nose and throat specialist) or an oral surgeon. Generally they'll do a biopsy, confirm the diagnosis, and then we get involved in diagnosing the rest of the mouth. So let's determine what else is wrong in the mouth, so we have a plan for restoring the mouth once radiation and chemotherapy is done with, because our goal really is, we want cancer to be gone, but we want you to live your normal life as much as possible.

So we want you to fold back into society and not be thinking about being a survivor, just to be a survivor and to feel normal. And so that usually involves extraction of teeth that are infected with periodontal disease or some sort of other large cavity that might need to be extracted in the future, so preventative extractions, that's kind of the simplest form of our integration into the team.

Depending on how large the cancer is, we'll also help plan the resection. So if someone has jaw cancer, for example, and a portion or their entire jaw has to be removed, the fibula, so one of the bones in the lower part of the leg, is used to reconstruct the jaw or the maxilla, the top jaw.

So, generally, we'll help plan that. The reason is, we want to plan for where the future teeth should be if our timeline allows us, and again, that goes back to the diagnosis. Is this something that's malignant and has to be operated on immediately, or is this benign, and we can take a little bit of time, plan everything perfectly?

Host Amber Smith: Does reconstruction happen at the same time the tumor is removed, or are these two different operations, where you take the cancer out first, and then you come back and work on the reconstruction in a separate surgery?

Arthur Bigsby, DDS: It depends on the diagnosis and how much time you have. So, if someone has a benign cancer, meaning something that's not spreading throughout their body, then you can plan, let's call it a perfect surgery, where you could remove the cancerous portion of the jaw, harvest bone from the leg, put it in the jaw, place implants at that time and let the patient heal. Maybe you don't place implants because of future treatment, like, if radiation's involved. Maybe you do. It all depends on the diagnosis and treatment plan. That's in a benign scenario.

In a malignant scenario, sometimes you don't have that time, so you need to just remove cancer, get the patient cancer free, and then plan restoration after-care.

Host Amber Smith: It sounds like some of these surgeries can be rather extensive.

Arthur Bigsby, DDS: Yeah, absolutely.

Medical insurance does a good job of covering this. You know, you're not using your dental insurance. Dental insurance is more like a coupon, where medical insurance covers treatment. And so, typically anything that's done the day of surgery will be covered by medical insurance. For example, if someone has teeth removed because they have oral cancer and the teeth are going to cause a problem down the line, if the teeth are removed at the time of oral cancer surgery, then those teeth will be covered by medical insurance.

If they're removed down the line, then typically medical insurance won't cover them. And, so, it's a lot of paperwork fighting with insurance companies for those reasons, and prostheses are sort of in the same boat.

Host Amber Smith: Well, after surgery, how do you counsel your patients about the recovery period, where they may not be able to speak or eat or swallow?

Arthur Bigsby, DDS: I like to break it down into, like, long-term and short-term changes. Certainly, the first two weeks after surgery are going to be difficult. That's where there's very limited eating, speaking, things like that. And that's best to sort of consult with your surgical team, just because everyone's different. Some people might have food that's not even going through their mouth. They might have a tube placed in their stomach to kind of allow everything to heal in the throat or in the mouth. But if someone is able to eat, and they're off some sort of clear liquid restriction, usually it's anything that can be squished with a plastic fork as the general suggestions, so it's something very smooth and easy to eat. You want to just try to eat whatever you can, so you don't need to worry about calories. So if you can only get a milkshake down, get the milkshake down, because your body just needs calories. That's the eating part, but more importantly, sort of the side effects of treatment.

In the short term, with radiation, there's going to be mucositis, which is sort of like a sunburn inside the mouth or like a pizza burn in the mouth. Usually comes on around week two or three of radiation treatment and lasts for about as long as treatment was. So, for example, if you had seven weeks of treatment, around week 14 from the start date, you'd be without the mucositis, so those sores would be gone.

Other changes you're going to expect, more sort of long-term changes, are saliva changes. So your saliva will decrease initially, hopefully return in some capacity, probably never back to 100%, but that all depends on the diagnosis and location of the cancer. And also changing consistency. Maybe it'll become more ropey and thick, and so that's something to expect.

And there's different medicaments (medications) we can use to help replace the saliva or stimulate more saliva.

And then lastly, the muscles are affected. Radiation decreases the elasticity of the muscles. They're less pliable, less like rubber bands. They're more stiff. And so a lot of stretching is good before treatment, during treatment if you can tolerate it. And then after treatment, for at least five years, so there's different routines that you can follow that will help maintain your opening.

Host Amber Smith: Well, what happens to dental care after a patient has gone through this? Do they return to the dentist and cleanings every six months, or do they have other concerns?

Arthur Bigsby, DDS: Generally, how radiation works is it decreases vascularity in areas, so there's less blood flow in areas that get radiation.

So you have to be careful about your dental care after treatment. So, yeah, absolutely, a patient should return to their dentist, see them at least twice a year.

Typically, we'll suggest maybe more often to start, because we want to stay on top of the oral hygiene because since there is less blood flow in the area of the mouth now that they've had treatment, there's a higher chance that things get out of control. So, periodontal disease could be a bigger problem or cavities that get big and need to be potentially extracted or a root canal done. We want to avoid those things.

So, being seen by a dentist more often is better once you've had care, but you can return to normal care. And then the key is you want to avoid surgery. So you want to avoid extractions, implants and deep scaling, which is like deep root cleanings, just because the body's not going to respond well, and you're at risk of what's called osteoradionecrosis, basically the body not healing in an area that surgery occurred in after radiation was delivered to that area.

Host Amber Smith: Very interesting. Dr. Bigsby, thank you so much for making time to tell us about your profession.

Arthur Bigsby, DDS: Thank you for having me. I really appreciate it, Amber, and hope you have a great day.

Host Amber Smith: My guest has been Dr. Arthur Bigsby from the Upstate Dental Clinic faculty. He's a maxillofacial prosthodontist.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/informed.

This is your host, Amber Smith, thanking you for listening.