Geriatric emergency care; donating one's body to science; facial and dental repair: Upstate Medical University's HealthLink on Air for Sunday, June 11, 2023
Jay Brenner, MD, tells about geriatric emergency medicine, or GEM Care. Dana Mihaila, MD, PhD, discusses the anatomical gift program. Arthur Bigsby, DDS, explains the wide-ranging role of maxillofacial prosthodontics, a dental specialty.
Host Amber Smith: Coming up next on Upstate's "HealthLink On Air," an emergency physician tells about providing emergency medical care for older adults.
Jay Brenner, MD: ... This unit is staffed by nurses, physicians, other health care professionals who are trained to take care of patients who are 65 years and older. ...
Host Amber Smith: The director of the anatomical gift program explains how donations help students learn anatomy.
Dana Mihaila, MD, PhD: ... The study of anatomy dates back to the ancient Greeks, and the first use of human bodies for anatomical research and education occurred in the fourth century B.C. ...
Host Amber Smith: And a maxillofacial prosthodontist discusses the care he provides.
Arthur Bigsby, DDS: ... 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. ...
Host Amber Smith: All that, and a visit from The Healing Muse, after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.
On this week's show, we'll learn about the anatomical gift program. Then we meet a maxillofacial prosthodontist. But first, we visit with the director of geriatric emergency medicine, or GEM Care.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
Upstate Community Hospital's emergency department recently achieved gold standard accreditations for its care of older adults in the GEM Care unit. That's G-E-M, for geriatric emergency medicine.
Here to explain why GEM Care is so important is Dr. Jay Brenner. He's the medical director of GEM Care and also of the emergency department at Upstate Community Hospital.
Welcome back to "HealthLink on Air," Dr. Brenner.
Jay Brenner, MD: Thank you, Amber.
Host Amber Smith: This may be the first listeners are hearing about GEM Care, so I'd like to start with a description of what this is.
Jay Brenner, MD: Absolutely. GEM Care is, as you said, the geriatric emergency medicine care unit that opened in 2013, 10 years ago, at the Upstate Community Hospital emergency department. And I've been a part of it since then. It is a dedicated eight-bed area within the emergency department, in a separate room, that has all of the physical plant features that one might want if you were a senior seeking emergency care. There's natural lighting from a large window. There's softer flooring that doesn't quite make the same loud noises that you hear throughout the rest of the hospital. There's digital clocks, for each of the beds, with noise-reducing curtains between each of the bays, so that you can see what time it is and not be disturbed by others around you.
Most importantly, though, this unit is staffed by nurses, physicians, other health care professionals who are trained to take care of patients who are 65 years and older, and pay more attention to some of the intricacies of taking care of patients in that age range.
Host Amber Smith: Is GEM Care open the same hours -- 24 hours -- like the emergency department is, or does it have certain days and times?
Jay Brenner, MD: Yes. As you just mentioned, the emergency department is open 24/7/365, and the geriatric emergency medicine care experience is provided during all 24 hours, seven days a week, 365 days a year. The actual space of the GEM Care unit is sometimes closed during slower hours. And so, it depends on staffing.
That actual space may actually be not used during the wee hours of the morning. But on the most part, it is part of our functional space in the emergency department. And, again, the geriatric emergency medicine experience is open all the time.
Host Amber Smith: Who qualifies to be seen at GEM care? Is it anyone over age 65?
Jay Brenner, MD: Yes, quite simply, 65 and over is the age cutoff. If someone is in dire illness or injury where they're really at the extremes of cases that we see where their life may be under immediate threat, they may be seen in the regular part of the emergency department. But they will still be getting sensitive, senior-friendly care.
Host Amber Smith: Does a person need to call first, or do they just arrive?
Jay Brenner, MD: We don't currently have a mechanism by which to expect patients who might call about coming into the emergency department unless they would be being transferred from another hospital or facility, such as an urgent care or doctor's office. Certainly we do take those sorts of calls. There is no need to call ahead. We are an emergency department and open, as I already mentioned, 24/7/365. We're ready for you.
Host Amber Smith: Does it cost more for patients if they go to GEM Care than it would to the regular emergency department?
Jay Brenner, MD: No, of course not. It's an emergency department bill. So in that sense, it may cost more of your copay than, for example, a doctor's office visit or an urgent care visit, but it is equivalent to the emergency department.
Host Amber Smith: Do you know what percent of emergency patients are over age 65?
Jay Brenner, MD: Right. So we're seeing about 15% to 20% of our patients arriving in that age category.
Host Amber Smith: And are there projections for how this may grow in the coming years or the need for more GEM Care?
Jay Brenner, MD: Oh, absolutely.There are some estimates that put it at 40% to 50% of emergency department visits by 2050.
But what we've seen personally in the last 10 years when we opened the GEM Care unit, we increased our geriatric patients who were visiting -- that is, our senior patients 65 and over -- at about a rate of 15%. So we saw an increase. Not a stark increase. And perhaps as awareness gets out there that we are now level 1 gold-level certified geriatric emergency medicine -- which is quite a feat that we have achieved; you know, I think we're only the 25th emergency department to have that designation in the country, and the first in Upstate New York -- I think we may see an influx of even more patients seeking out that care. But it's something, certainly, that we'll pay attention to.
Host Amber Smith: Now we're talking about Upstate Community Hospital campus. What about downtown, at Upstate University Hospital? Do they have GEM Care as well?
Jay Brenner, MD: It's something that we are contemplating, extending the geriatric emergency medicine experience to our downtown hospital. In the meantime, there are some select components of it. For example, there is a effort to get patients who suffer a hip fracture to the operating room within 24 hours, as part of what's called the ortho co-care initiative, which is tapping into some of our knowledge and skills with our geriatric emergency medicine experience to try and get patients to the operating room within 24 hours. And that's happening both at Community and downtown.
And then there are some other efforts, like trying to make sure that our medications are properly dosed, whether they be pain medications or sedative medications. And we're making sure that those are properly dosed at both departments.
Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with Dr. Jay Brenner. He's the medical director of the GEM Care unit at Upstate's Community Hospital.
So tell us about the gold standard accreditation. How did you earn that?
Jay Brenner, MD: Yeah. So, the American College Emergency Physicians, ACEP, which is the leading professional society of emergency medicine, actually started accrediting geriatric emergency departments in 2018 and giving them either a gold, silver, bronze or Level 1, Level 2, Level 3 status.
And we looked into it at that time and started to prepare our data to share with them, and then COVID hit. So the COVID pandemic sort of waylaid us. We had to repurpose our GEM Care unit for COVID patients because it was a very good space to take care of patients in negative (air) pressure, which prevented the germs from spreading.
And then we looked at it again when the founding medical director, Dr. Jamie Ciaccio, of GEM Care phased out of clinical work into telemedicine work, and then eventually retired at the end of 2020, upon which I took over the unit and worked with our hospital quality services liaison, Amy Serzanin, to really build up our data.
We submitted our application in July of 21. And after a couple of back-and-forth go-arounds with ACEP had a visit from the reviewers, virtually, in February of '23. And they met as a board in April of this year and gave us the gold standard accreditation.
Host Amber Smith: Can you give us some examples of guidelines that ACEP established for geriatric EDs, or geriatric emergency departments?
Jay Brenner, MD: Yes, of course. So it requires not just staffing and education, but a series of policies and procedures that you can show you're adhering to. And so we, as a gold level, Level 1 geriatric emergency department, we have to adhere to 20 or greater policies. And these policies include things like the medication dosing that I mentioned, but also avoiding Foley catheters (tubes to drain urine) unnecessarily. Also providing mobility, promotion and ambulatory assessments, so making sure that people can walk and get out of their stretchers, making sure they're getting food as soon as they can, making sure that they're getting case management to help them get into either home care arrangements for physical therapy and occupational therapy at home or into skilled nursing facilities if they need it. And so all of these policies, including also fall risk prevention and dementia and delirium screening, all sort of fit into the whole geriatric emergency medicine experience.
And that's what ACEP has been really focused on making sure that we're providing soup-to-nuts senior friendly care from the time that you approach the triage nurse and the registration clerk to the time that you leave the emergency department, either to hopefully go home with the services you need or enter the hospital for inpatient care.
Host Amber Smith: I was going to ask, do most GEM Care patients get released to go home, or do they get admitted to the hospital?
Jay Brenner, MD: Yes. Most geriatric emergency medicine patients do go home. Our admission rate at the Community emergency department overall is about 20%. And for patients 65 and over, it does go up to about 30%. But on the most part, patients will go home.
Host Amber Smith: So most of them, you're able to get stabilized and comfortable and well enough to return back home?
Jay Brenner, MD: Exactly, and that's the goal. We even tolerate even sometimes longer lengths of stay in the emergency department if we can provide the services to avoid an admission because we know that while there are some conditions that need to be managed inpatient, ideally the services can be brought to the patient at home.
As I think our audience may be aware, even when you need inpatient care, there is a special program that involves Upstate's "Hospital at Home." And so there are some conditions that need hospital care, but after coordinating with our case management team, we are able to get patients -- for example, IV (intravenous) antibiotics and oxygen therapy -- things that they might need in the hospital, but actually at home with nursing care.
Host Amber Smith: So what are the most common medical issues you see in this patient population?
Jay Brenner, MD: Oh, that's a good question. It varies. Obviously, one of the things we saw earlier on in the COVID pandemic was COVID itself, as we are well aware in geriatric emergency medicine, was more than anything a geriatric emergency. It really impacted the morbidity and mortality (sickness and death) of our senior adults quite a bit. That being said, as we are crawling out of the pandemic, we are certainly seeing other infections, whether it be flu or bacterial infections. Sepsis is a very common phenomenon in the geriatric population. And then patients will have various causes of delirium, like infection, but also other metabolic issues, cardiovascular disease, cerebral vascular disease, in other words, heart attack and stroke.
And a very common phenomenon, as well, is trauma. And usually that trauma comes in the flavor of falling. We see quite a bit of injuries from falls, and that's why we spend a lot of time trying to work on fall prevention. But then when falls happen, we try to not only identify the injuries that may have been suffered during the fall, but also the underlying reason why a patient may have fallen.
Host Amber Smith: Why do you enjoy working in geriatric medicine?
Jay Brenner, MD: Geriatrics is very exciting because these patients have actually very complex medical histories, often. And it can be a challenge that is both invigorating and rewarding to take care of. I'm doing this for my 81-year-old mother and my 74-year-old mother-in-law who access this care not infrequently. It gives, I think, our community great comfort to know that there's people sort of looking out for them as they age, hopefully gracefully.
Host Amber Smith: Do you have any advice for family members or friends who need to bring an older person to the hospital?
Jay Brenner, MD: Yeah. I'm so glad you asked this question, Amber, because when you're deciding if you should come to the emergency department or not, and perhaps you call your doctor or maybe a family member who is in health care, and they advise you to go to the emergency department, we certainly want you to come, but don't forget to bring some of the important things that will help us take better care of you.
Medication lists that are updated is one of the top things. Any assistance devices that you might need. So, we have walkers, so if you don't bring your walker, that's OK. We have walkers. But bring your hearing aids. We do have amplifiers if you forget them for some reason, you are leaving a hurry. you know, bring your visual aids, your glasses, right? Don't forget that in order to best take care of you, we need to be able to communicate with you. And whatever assist devices you need, that's really helpful.
And then for advocates, for family and friends that are bringing in a senior adult to seek emergency care, bring yourself. Visitors are welcome. We've, definitely made our visitor restrictions much more lenient as we're having much lower COVID rates. And so you need to come and advocate. We know that patients who have an advocate get sort of more attention for their needs, and we welcome you to do so.
One thing that I think is good to leave at home, and I shouldn't have to spell this out per se, but we've had this happen on occasion. You can't bring your pet, unless they are a registered service animal. And I realize that can be a little bit disconcerting because a lot of older adults really do find a lot of companionship and support by their pet, whether they're cat or dog or iguana. It's not something that we can accommodate for in this shared space.
The other thing is, as of this past Thursday, you no longer need to bring your mask. And honestly, you don't have to wear a mask. Masks are optional in our space. And we're of two minds with this. Certainly we want to reduce infection. But we're realizing that the mask was getting in the way of ideal communication. Certainly over the last three years of this pandemic, on many occasions I've worn a translucent mask so that patients could see my face through the mask protection and actually be able to perhaps lip-read if they were relying upon lip-reading. So you don't need to bring your mask. We welcome you, mask optional.
So just adding that in to the mix. And other than that, we have warm blankets. We have lots of comfort items, but I've seen patients on many occasions bring their own blanket, and that's OK. We're, not going to tell you to leave that at home. But certainly wear comfortable clothes because you are going to be asked to get into a patient gown like you would at any health care facility. And certainly there are people to assist you with that if you need assistance. And that's really about it. I mean, just bring yourself and any contact information that you might have for anyone that can help us best take care of you.
One other thing I should have mentioned. It's a bit of a sensitive topic, so I hesitate, but I think it's important that if you do have Medical Orders of Life-sustaining Treatment, or a MOLST form, that would be something that would be good to bring. It's good to know what your wishes would be if there were any extreme measures that were needed to take care of you.
Host Amber Smith: Dr. Brenner, thank you so much for making time to tell us about GEM Care.
Jay Brenner, MD: Great. Thank you so much. And, hopefully you don't need our services, but if you do, you know where we are. And we're always glad to see you when you come.
Host Amber Smith: My guest has been Dr. Jay Brenner, medical director of the emergency department at Upstate Community Hospital and of the geriatric emergency medicine, or GEM Care unit there. I'm Amber Smith for Upstate's "HealthLink on Air."
What you need to know about making an anatomical gift -- next, on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
An important part of medical school and physical therapy training is learning human anatomy, and people who choose to donate their bodies to science contribute significantly to educating these health care professionals.
We'll learn more about how and why people donate their bodies from Dr. Dana Mihaila. She is director of the Anatomical Gift Program and the anatomy lab at Upstate.
Welcome to "HealthLink on Air," Dr. Mihaila.
Dana Mihaila, MD, PhD: Thank you very much, Amber.
Host Amber Smith: Now, Upstate students organize an annual memorial service to pay tribute to those who donated their bodies, and I know that's very meaningful to many of the survivors who come, as well as the students.
How do you describe the services that you've attended over the years?
Dana Mihaila, MD, PhD: The memorial service is a token of appreciation that honors our donors. It reflects our gratitude and respect for all the donors to SUNY Upstate Anatomical Gift Program, and in the same time, our deep appreciation for the compassion and support of their families and friends who attend this memorial service.
Host Amber Smith: Can you talk about what students gain from participating in the anatomy lab?
Dana Mihaila, MD, PhD: You know, anatomy has always been the cornerstone in the field of medicine. The study of anatomy dates back to the ancient Greeks, and the first use of human bodies for anatomical research and education occurred in the fourth century B.C.
Knowledge of the human anatomy forms the basis to the understanding of normal body functions and of the pathology behind all the diseases.
Host Amber Smith: This is required training for anyone who's going to become a doctor, also physical therapist as well. Are there other medical professionals that do the anatomy lab training?
Dana Mihaila, MD, PhD: Yes, there are. Every health care professional needs to have an understanding of human anatomy, some of them more in-depth than others. All students from our university benefit of the anatomy laboratory.
The students that spend more time are the Doctor of Physical Therapy and physician assistant programs. They spend several months in the anatomy lab.
And the Doctor of Medicine program students spend one whole year.
Host Amber Smith: With so much education available virtually online, how does a literally hands-on class like this compare?
Dana Mihaila, MD, PhD: For health care professionals, the human body is the focus of investigation and intervention on a daily basis.
For this reason, the study of anatomy on human bodies is essential to safe medical practice. The anatomy laboratory experience improves students' understanding of what they do and why they do it. This surely has to be of benefit both for the safety of the patient and satisfaction of the doctor as a professional.
Integration of newer and modern technologies is an addition to the anatomy laboratory, which helps retention of anatomical knowledge and its clinical relevance.
Host Amber Smith: Can you tell us how anatomy is taught? Do you go system by system, organ by organ, or is it disease-specific? How do you go about teaching today's, or the future, doctors anatomy?
Dana Mihaila, MD, PhD: In our university, we have a curriculum that, it's system-based, and anatomy is taught in every system being integrated with physiology and pathology and all the other disciplines.
So, for instance, to give you an example, our medical students will start in the beginning of the year by studying musculoskeletal system from all the aspects that this involves. They continue with the study of the nervous system, cardiovascular system, respiratory, renal, endocrine and gastrointestinal. So, almost every month, every six weeks, they will switch to another system, and they are going to learn about the system from every perspective, anatomy being one of them.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.
I'm talking with Dr. Dana Mihaila. She's the director of Upstate's Anatomical Gift Program and the school's anatomy laboratory.
For relatives who have a family member who donates their body, how does that impact a funeral or memorial service?
Dana Mihaila, MD, PhD: Many families choose to have a memorial service without the donor being present.
Host Amber Smith: For how long are the bodies used at the medical school?
Dana Mihaila, MD, PhD: Our donors spend up to two years with us.
Host Amber Smith: What happens to the person's remains when the class ends?
Dana Mihaila, MD, PhD: When the class ends, each donor is cremated at the university's expense, then the donor's cremains are returned to the family or to the person appointed by the donor.
Host Amber Smith: Let's talk about how people can become donors. Are there age requirements?
Dana Mihaila, MD, PhD: Yes, there are. The donor should be 18 years old and above. The program doesn't have an upper age limit. Our oldest donor was 107 years old, and we wish our future donors to reach at least this age. People interested in donating to our program can call us, and we provide a brochure explaining the whole process.
Host Amber Smith: So, Dr. Mihaila, if someone listening to this is interested in becoming a donor, is there a phone number or an email address for them?
Dana Mihaila, MD, PhD: Yes. Our phone number, it's 315 (area code) 464-8582. And our email address, agp -- this stands for Anatomical Gift Program -- @upstate.edu (firstname.lastname@example.org).
Host Amber Smith: So is there paperwork? There must be paperwork to fill out ahead of time, right?
Dana Mihaila, MD, PhD: Yes, in the brochure there is paperwork necessary for donation. Most of our donors make a pledge during their life. For some of the donors, their family makes the decision.
Host Amber Smith: So a person can make the decision prior to death, or their family members or their survivors might be able to make the decision afterward.
Dana Mihaila, MD, PhD: Exactly.
Host Amber Smith: What could disqualify a person from being a donor?
Dana Mihaila, MD, PhD: There are criteria for donor acceptance into our program. All of them can be found in our brochure. Some of the ones that disqualify a person from becoming a donor are infectious disorders, contagious disease, organ donation, and there is a weight requirement relative to the height of the person.
Host Amber Smith: OK, so just because you want to make this donation, you might not be able to, depending?
Dana Mihaila, MD, PhD: Yes. There are situations when this is the reality.
Host Amber Smith: What happens if someone who signed up and said they wanted to be a donor dies when they're not in the Syracuse area?
Dana Mihaila, MD, PhD: First of all, SUNY Upstate's program doesn't cover just Syracuse area, it covers Central New York area. If a person dies closer to another medical institution and outside our area, we guide and help the family to connect with that university. There are some donors, they live in our area, but wintertime, they go to Florida, for instance, and we encourage them to pledge to both programs, to our university and then university in Florida.
And it's very possible. It's no restriction to pledge to more than one program.
Host Amber Smith: Over the years, when you've spoken to people who are making the decision to donate their bodies upon death, what are some of the reasons they give for wanting to do this?
Dana Mihaila, MD, PhD: I can say that the main reason that our donors pledge to the program is to advance medical education and research. Along the years we met isolated cases when financial considerations contributed to the decision.
Host Amber Smith: Is there any financial compensation for donating?
Dana Mihaila, MD, PhD: Donation is a gift. It's no compensation, but the university is going to take care of the cremation.
Host Amber Smith: I can't imagine myself, and I want to ask you, can you imagine someone becoming a doctor without having hands-on anatomy training in a lab like this?
Dana Mihaila, MD, PhD: If you ask my personal opinion, my answer will be, with capital letters, NO, I cannot imagine. I am a trained physician, and I can tell you that the experience in the anatomy laboratory doesn't have any other equal.
Host Amber Smith: Well, Dr. Mihaila, thank you so much for taking time to tell us about this.
Dana Mihaila, MD, PhD: Thank you for having me.
Host Amber Smith: My guest has been Dr. Dana Mihaila. She directs the Anatomical Gift Program at Upstate and also the anatomy lab. I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air," the role of a maxillofacial prosthodontist.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
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 "HealthLink on Air," 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 (an imprint from a patient) 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 "HealthLink on Air," with your host, Amber Smith.
I'm talking with Dr. Arthur Bigsby. He's a maxillofacial prosthodontist and a 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 suggestion, 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.
I'm Amber Smith for Upstate's "HealthLink on Air."
Here's some expert advice from Dr. Jeffrey Albright from Upstate Medical University. What symptoms might signal colorectal cancer?
Jeffrey Albright, MD: So people that experience bleeding would be one thing. Usually if somebody has a cancer or tumor that's further down, it's more likely to cause bleeding that they can see. If people have unexplained anemia. Most cancers are larger polyps that occur further up in the colon, so further away from the anal area, tend to just cause slow blood loss over the course of time.
And it's maybe anemia that gets identified by their primary doctor that needs an explanation. Anemia for most people is not a disease, it's just a sign of something else going on, so that's something we also want to be very sensitive to.
People that have changes in their bowel function, so if they're having worsening constipation that they can't explain over the course of a few months, or if their stools are coming out narrower, or if they've got unexplained diarrhea, if they've got bowel crampiness or abdominal pain that can't be explained, those can be signs of colon cancer. They can also be signs of a number of other things, but those can be signs of colon cancer.
And then probably the other thing that we think about as well is just knowing your family history, knowing if you've got a parent who's younger who developed colon cancer, if you've got a number of different first- and second-degree relatives who have had colon or rectal cancer, then there may be some underlying issue related to your genes. There could just be some type of a predisposition to developing cancers at a younger age.
Typically, the way that we try to approach things with people that are a bit younger, especially ones under the age of 45, is, it really depends on their overall symptoms.
And we know that somebody, if they're in their 20s, and they don't have a family history of having cancer of specifically the colon or the rectum, that the likelihood of having a little bit of bleeding on the toilet paper, something like that, is unlikely to be colon cancer. But as we start to see people as they get into their 20s or 30s, or if they start having more warning signs as far as blood or changes in their bowels or pain that we can't really explain in any other way, we will often start to recommend doing a colonoscopy or some other type of study to evaluate the colon, just to make sure that we're not dealing with a young person who does have a colon cancer.
Host Amber Smith: You've been listening to colorectal surgeon Jeffrey Albright from Upstate Medical University.
And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: Physician and poet Tai Wei Guo gives us a portrait of a young girl in the hospital, reflecting on the sounds and sights all around her, as she tries to be brave.
Here is "Brave":
Machines in the hospital can cry, but brave little girls do not.
Little girls who cry startle doctors who ask "what's wrong?"
Doctors feel like they have to fix everything.
When your bones are broken, they fix your bones;
and when your bones are dislocated, they locate them.
When your pancreas is broken, they excise the tumor;
when your spirit is broken, they try to exorcise the fear.
Meanwhile, machines in the hospital sing all day of apocalypse:
Air in line, occlusion downstream, air in line, infusion complete.
Machines in the hospital are actually metronomes
because they count every lonely second with you.
Lub-dub pa-chik lub-dub pa-chik lub-dub pa-chik lub-dub --
Brave little girls whittle away at time watching Van Helsing.
Brave little girls read books like Dawkins and know there is
no use crying over statistics: someone had to be unlucky.
Brave little girls know refusing morphine is a sign
of strength and refusing faith is a sign of science because
refusing pity is the highest sign. Bravery is being content
watching ships outside the window barging downstream.
Except it doesn't feel brave to watch your mother crying.
Here is the secret: brave little girls are just
little girls because they never chose to be brave.
What else is there to be, with half a pancreas
and a line of staples holding their guts together.
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air," can fecal transplants work better than antibiotics?
If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.
Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.
This is your host, Amber Smith, thanking you for listening.