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Winter Park Dentistry-Canker Sores, Herpes, Oral Cancer (part 2)




Dr. Ramzi Matar (Winter Park Dentistry): It’s probably common sense if you’re a dentist… Then you said something interesting… Two points I want to bring home, you said something about it not being contagious after it crusts over, so if you see like a shell crust over it, now it’s healing…

Dr. Indraneel Bhattacharyya: Yeah, like in any other sores on the body. It’s the same thing. You don’t have to treat it…

Dr. Ramzi Matar (Winter Park Dentistry): It’s over, it’s just healing. So, the other thing, now, this virus lives in the nerve, you said it travels back up, so it actually lives in one of the nerves in your mouth?

Dr. Indraneel Bhattacharyya: Absolutely. Not just our nerve, it can be anywhere in our body, but typically since we’re talking about oral herpes, it usually lives in the head and neck system. Very very similar to the herpes zoster virus, which is actually the chicken pox virus. Fortunately for humans, that virus gets activated in a much smaller group of people, not everybody can get it. Like, not everybody gets shingles! For example, I got shingles about 4 years ago, and it’s a pretty devastating painful condition, those who have had it can now, it travels through one’s nervous systems and attacks that one particular area… It’s also contagious, but not as contagious as cold sores fortunately, because people can catch chicken pox, if you have chicken pox as a child, you’ll be immune to it, but for an adult the advice would be is to take a vaccine for chicken pox or shingles, patients over the age of 50 or 60 should be getting a vaccine from shingles. And shingles can affect the mouth, and very severely so.

Dr. Ramzi Matar (Winter Park Dentistry): Next topic. It’s a big topic, we’ve already discussed it I think, we just have to hit some highlights because we could go on for days about this, I know I’ve seen you lecture for two days about oral cancer. But it’s a big buzzword out there, obviously you hear it often enough, I think it’s the leading cancer out there, it’s a pretty big player out there. So to everybody who’s watching this, and trying to learn about oral cancer, who are the highest at risk, what age group, males, females, and what kind of social habits you need to be more cautious with? And as a patient watching this, what not to ignore? Clearly, it’s never possible to diagnose without biopsy, and that’s kind of what you do all the time, but if you were just giving general advice, what should somebody watching this video not ignore?

Dr. Indraneel Bhattacharyya: One of the biggest things that we tell everybody, and for somebody who’s watching it such as a patient, I would say, never ignore a sore that has been there for more than 4 to 6 weeks. Never, whether you think it’s a cold sore, fine, it could be a cold sore that has lasted unusually long, but if it’s a canker sore, it should not last 4 to 6 weeks. The other thing I tell people if it’s in a high risk location, and what do we mean by high risk location? Most of the dentists in this country agree that it’s the side of the tongue, bottom of the tongue, the floor of your mouth, which is the soft part below your tongue, the soft palate, these are the high risk spots. You sure not have a sore there. We can have a, let’s say, a potato chip and it’s poked you in the roof of your mouth or on the floor of your mouth and created a sore. It should disappear within 4 to 5 days, you put salt water or maybe you used a mouthwash and it went away. That’s great. However, if it doesn’t go, and you do remember biting, that may be just a coincidence. Any sore that has lasted for more than 4 to 6 weeks should be looked at by a professional. And that professional could be your dental hygienist, or your care specialist, even general physicians, if you don’t have access to anybody or you trust nobody else, go to your physician. You tell them “I’ve got this for about 4 or 5 weeks, should we do something about it?”, and they can usually give you guidelines.

If it’s painless, that’s a bad sign. If you have a sore on your tongue, and somebody, dentist or dental hygienist touches the sore and you tell them “no, it doesn’t bother me”, that’s NOT a good sign. Because most traumatic sores, like canker sores, they are excruciatingly painful, all these kind of sores, from 1 to 10, the pain usually goes from 7 to 10! On cancer, unfortunately, it’s close to 0 and 1, there are hardly any symptoms. By the time they show symptoms, it’s usually very advanced, which means it’s penetrated into nerves and they’re chewing on the nerves essentially, and the muscle, which is what is causing pain. Other than that, I do want to say, you mentioned bad habits… That was the traditional thought, we knew tobacco and alcohol, especially the combination of the two, that was the worse. And it’s dose related, so somebody who smokes two packs a day, drinks two beers a day, has a higher risk than somebody who smokes 7 cigarettes a day an alcoholic drink a day. It’s a dose dependent process. Unfortunately, more and more we’re becoming aware of another entry in this business, that we didn’t know, the human papillomavirus, that has started to cause quite a few oral, and especially oral faringian cancer, so back in the throat area, and this affects young urban males, for some reason, in cities like New York, San Francisco, Los Angeles, Chicago… We are noticing a huge increase in young males, and in most of these they are doing well, with jobs, with income, enough nutrition, so I’m not just saying monetarily but…

Dr. Ramzi Matar (Winter Park Dentistry): They are generally healthy people.

Dr. Indraneel Bhattacharyya: Yes! And it is transmitted through sexual contact. Most studies have found 6 or more partners over the time of somebody’s life, which puts them at a higher risk. There’s a vaccine, that should be given to young men and women, less than 13 years of age. It’s considered to be very effective in blocking this virus. Now, having said all that, somebody wrote the cancer is caused by the virus. It’s by far much more favorable, in terms of how they’re going to do and live, and how much tissue will they lose from surgery… Everything is better for a person with a virus induced cancer than with a non-virus induced cancer, so tobacco related cancers. Or using scientific terms, a carcinogen related cancer. It’s far worse in prognosis, than the HPV related cancer, which has much better prognosis.

Dr. Ramzi Matar (Winter Park Dentistry): The HPV one, was that what Michael Douglas battled a few years ago, made the headlines?

Dr. Indraneel Bhattacharyya: Michael Douglas is one who made that very well known, yes.

Dr. Ramzi Matar (Winter Park Dentistry): Yeah, lots of people asked me about it, I guess it is true.

Dr. Indraneel Bhattacharyya: Studies took say, 1000 people, and found that most males and females already have HPV in our systems. We already have it, it’s pre-existent, we’re exposed to it through our lifetime. That is why we see suddenly a cancer in a 65 year old male, who’s retired, who’s living healthy, has good nutrition… Suddenly there’s a carcinoma in the back of his tongue, and we test it for HPV and it’s positive, they start to say “maybe he was sexually active?”. No! It was this virus that was probably living in the area, that for some reason got activated. We don’t know what those reasons are, we still haven’t established that, we don’t understand it.

Fortunately I can tell you all cancers remain a disease of older folks. It is not young people who get this cancer today, and unfortunately smoking, or drinking may not be in their lifestyle, but people are always open to getting a cancer. They’re vulnerable to it, we don’t know why that happens. What people can do is, especially citizens who are non-medical people, your patients, should be aware of a sore that does not heal, don’t take sores that do not heal lightly, take them very seriously. Show them to your dentist. Most dentists who are licensed in Florida, are very well-trained, they know what to do, they will immediately refer you for a biopsy. That is, by the way, the only way to diagnose it.

Dr. Ramzi Matar (Winter Park Dentistry): That is interesting. A little bit of a selfish question that I want to know, because last time I heard you lecture about the diagnosis, clearly yes, I do know the take-home message for somebody watching this, 4 to 6 weeks, non-healing lesion, get somewhere. Now from a clinician point of view, there’s different ways an exam, and oral cancer exam. For me, I was taught with a mirror, I’m looking visually, I have my loops, my light, and I’m palpating and doing the traditional exam. There’s a velscope, vizilite, there’s brush biopsies… Any strong evidence that there is something new out there, some camera, anything like that, that’s superior, breaking ground? If I have a patient, and I’m concerned, should I look for a dentist with one like these, or what are your thoughts on that?

Dr. Indraneel Bhattacharyya: That’s a very good question, Ramzi. There are machines out there. Unfortunately, one of the question was, “is there evidence that it helps?”. Unfortunately, to date, there is not a single device out there that gives you greater power to detect something that is hiding in your mouth. There is not. You might get lucky with a velscope, you may get lucky with your vizilite - which is a dye, commonly green dye, you treat the patient with this acid and then shine a light on it, the theory is it should highlight areas which are atypical. The scientific issue behind the problems we are facing with these devices, all of them work to a certain extent, but the problem is if you have a cancer, and I’m going a little bit into depth of molecular biology, in cancers, what happens is, tissue turns over, cells are multiplying faster. There are several oral conditions when tissue multiplies fast, for example, if I chew on my cheeks. If someone habitually chews on their cheeks, what you’re doing is turning tissue over faster, it sheds off. There are other conditions that do similar things, and if you use vizilite, it might highlight areas like these, and yes, you are helping the patient, but you might also be creating unnecessary stress.

So like you, I prefer having a light, a mirror, and what I do is lift the tongue up… For dentists, I would say, if you examine the tongue, the floor of the mouth, it can already rule out 85% of chances of finding a cancer. Then you take a good quality light, and you look at the back of their mouth, ask them to say “ah”, and you don’t notice any abnormal growths or sore. You rule out almost 100% chances of finding cancer. There are types of cancers on the gums, but they’re rare. You can get cancer on the roof of your mouth, but it’s extremely rare. But then, when somebody tells you, “I’m a smoker, I’ve smoked for 30 years, recently quit.” I do a better job in their mouth, than somebody who’s a non-smoker, I would look more just to make sure that there’s nothing I find in the back. Like a white patch, not just a sore, cancers can be a thick white patch, or if they have a big rock on the back of their mouth. If they’re 65 years old, and they used to be a smoker maybe 20 years ago, but they haven’t smoked in years, I do a better job of examining those patients, whether I have a light or not. But if you do have one of these devices, you’re not gaining much more than doing a thorough oral exam with a good open light.

Dr. Ramzi Matar (Winter Park Dentistry): So, I really appreciate it. Last question. I could go on all day with you, I hope to have you on for more episodes. I know you’re the director of the residency at the University of Florida, one of the best residencies for oral pathology in the nation. My question, I also know you’re a big Colts fan, so if Andrew Luck decides to stop being one of the best quarterbacks in the nation, do you think he’d become a good oral pathologist? If he decides to quit NFL tomorrow?

Dr. Indraneel Bhattacharyya: Absolutely, I think he would be the best.

Dr. Ramzi Matar (Winter Park Dentistry): I think so too. But I’m not sure he’s going to give up his job with the Colts, he’s clearly proving himself to be one heck of a quarterback… If he’s watching this video, it’s good to know you think he could make a good oral pathologist, should he decide to make a change. Dr. Bhattacharyya thank you so much, I really appreciate your time, and toe everybody watching it, I hope you enjoyed it, please post your comments on our YouTube channel, we’ll do our best to reply or get any kind of feedback, but I think this is very informative, a lot of people need this information. Thank you.