How to Diagnose Oral Cancer and Premalignant Lesions

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Today we'll be discussing how to diagnose and detect oral cancer and pre-malignant lesions. Our guest is Dr. Lauren Levi, a dental oncologist and oral facial pain focused dentist based in New York with extensive experience treating a variety of oral medicine conditions. She is an adjunct clinical assistant professor at NYU College of Dentistry in the Department of Oral Medicine and Orofacial Pain and a clinical instructor and dental oncology attending at the Icahn School of Medicine at Mount Sinai. Dr. Levi, it's a pleasure to have you on Dental Talk. Pleasure to be here, Phil. Yeah, so we appreciate your time and we appreciate your expertise as a dental oncologist. That's really cool. How are things going at the dental school now with COVID? Are things going to be back to normal, at least for the dental clinic? we're actually trying to figure out those kinks currently but we are we've been virtual since March and we are opening up again after Labor Day and the idea is I think less faculty less student ratios everybody's gonna be waiting outside in terms of checking in and if there are you know procedures that are considered like high risk the students are going to be wearing N95s. I think they're still figuring out whether or not patients are going to be tested before. And that, I think, is kind of up in the air still. So still a little time to figure it all out. Yeah, I know. It's not easy. It's not easy. Getting to the topic of today's podcast, which is diagnosing oral cancer and malignant lesions. And again, this is a really important thing for our listeners to be aware of because... lot of these patients see dentists more often as the healthcare provider than their own physician. So it's really important that they have an idea of what the oral environment should look like pathologically. So what would you say the take-home message is when it comes to oral cancer detection? I think the take-home message is always to be to never stop looking. And if something lingers for two weeks, then the bottom line is to biopsy most likely. I mean, obviously depending on what the lesion looks like, but... think the key is every single time your patient comes in for a hygiene exam, at least once a year, if not, and they're probably coming in twice a year, right? So at least once a year, you want to make sure you're doing the oral cancer screening. I really think you should be doing it on both hygiene visits. If there is something there that looks suspicious, especially if it's in a high -risk zone, and that would be, you know, lateral borders of the tongue, ventral surface of the tongue, floor of the mouth. retromolar area, then what you want to do is take note of that, wait two weeks, and like I said before, if it doesn't go away, then biopsy the lesion. Yeah, we didn't get a lot of training on oral cancer diagnosis in dental school. Where did you become so knowledgeable on this? Because I know you teach dental oncology. Is that something you did on your own after dental school, or is there a program for it? Both. I did a dental oncology fellowship at Sloan Kettering. And then I also got a master's degree in orophacial pain and oral medicine at the University of Southern California. But in addition to both of those, or really after those, I really just focused on seeing cancer patients. So your practice focuses on seeing patients that have oral cancer. Yes. Well, it focuses on dental oncology as well as orophacial pain. So it's treating the side effects of cancer therapy. And so and that goes along the lines of like any type of cancer. So most of the time the patients do have oral cancer and sometimes, you know, they've already had oral cancer in the past and it's a recurrence or sometimes I'm seeing them before they've been diagnosed. And, you know, they've been referred by a colleague who's saying, you know, there's something on their tongue that looks a little suspicious. What do you think? Do you do the restorative work on them? Once they're in your practice, do you treat them as any dental patient would be treated under the conditions of their cancer? Yes. It's more oral medicine treatment, so it's more treating xerostomia, mucositis, some sort of pain, something like that, radiation fibrosis syndrome. But I do also do dental treatment on patients that have had a history of cancer or if they're undergoing cancer therapy. How many years after dental school were required to get to your level of expertise as a dental oncologist? It's just after. So I did a GPR. And then after that, I did a one-year fellowship. Very impressive. So how bad is it out there as far as patients walking around with oral cancer that are not being discovered by their general dentist? How bad? Yeah. What's the prevalence? Are we being a little bit slack about? not being really meticulous about checking our patients for oral cancer, or are we doing a good job as a profession, speaking on the GP side? I think we're doing better, but I still think we can, we're doing better than we were. but we could still do better especially when it comes to actually looking at cancer that's on the lip which is kind of shocking to me um because that's the e i mentioned it in my webinar webinar that that is actually the easiest one to find because it's literally staring you at the face and for whatever reason often when dentists find it it's it's usually pretty far along but the truth is if you see a lesion on the lip that looks ulcerated that looks like it's not going away Don't just assume, you know, the patient just, you know, scratched their lip or it's just a herpetic ulcer. You should look further and have the patient follow up with you. And if it looks like it's something that might need to be biopsied or explored further, don't neglect it. So the GP should be asking the patient how long is a question that's reasonable to say how long has that lesion been on your lip? Absolutely. Okay. So that's a big part of the medical history, the medical dental history. if you see something like that, and then what's the timeline where it becomes concerning? So it's always two weeks. I mean, I think that sometimes patients will not be so clear as to when they think it's been there. I think if it looks very suspicious and they think that it's been there for a while, then use your better judgment and either biopsy it yourself or refer it to someone that you feel comfortable could biopsy the lesion. If they say, you know, I'm not sure, then you know what, depending on what it looks like, right, you might be able to give them some sort of steroid or maybe it looks like a fungal infection to you or whatever you think that it looks like. You can give them some sort of medicament that you think might help heal the lesion. I mean, maybe it looks like they've been biting their tongue, right? So maybe there's something to that effect. Whatever you think it might be, then have them follow up in two weeks. And if it doesn't look like it's improving, then I think two weeks is the golden rule, then you should definitely biopsy. And how many GPs do you think actually do their own biopsy versus sending it to an oral surgeon or a specialist in oral medicine or somebody like you? That's a good question. I think it depends on the region. I think if there's limited access to care and you're in a more rural region, then GPs will be more likely to do it. But I think, I mean, I'm based in Manhattan. I think in big urban centers, then they're more likely to refer it out to a specialist. Yeah, that makes sense. And that actually applies to other procedures as well, for sure. If someone feels comfortable about doing a biopsy, when should they do a biopsy and when should they not do a biopsy? So rule of the two weeks, right? If the lesion looks benign in the sense of if you don't think it's suspicious, it's not in a high-risk zone, then do the biopsy and it looks small, then I would say you can biopsy the lesion but actually try to do an excisional biopsy, meaning remove the entire lesion. If it looks... little bit more ominous you know you're a little concerned that it could be malignant and it also looks pretty large then I would I would recommend doing an incisional biopsy meaning into it basically in a V go far deep but do not to try and do not attempt to take out the entire lesion before you biopsy lesion definitely take a photograph right and give the pathologist that's going to be reading this as much information as possible so you can say you can give your differential diagnosis you can give a little bit of history like patients you know big smoker and drinker or patient has um no history of smoking or drinking or patient believed that they were chewing their tongue or maybe whatever it could be a patient has a history of grapher's host disease elsewhere in the body patient has uh what appears to be like in planets elsewhere something like that so that you know obviously you want to guide them Also, make sure that you label kind of where you took the biopsy. In other words, like left to right when you're putting it down or anything like that. If you think that the lesion looks like a hemangioma, something like a blood vessel, then you don't want a biopsy, right? That can be concerning. You want to aspirate because obviously that can cause excessive amount of bleeding. I mean, this is all great information you're giving us. I'm just wondering, and again, I graduated dental school a long time ago, so I'm just wondering how many GPs would, if they saw something suspicious. like you said, they would try to do something therapeutic. And then two weeks later, if it's still there and there's not an improvement, they would say, you know what, I think I want to send you out for a biopsy. Isn't that the bulk of it? Wouldn't you say the majority of dentists would do that? They would send it out to an oral surgeon? Yeah, I think so. I think unless, like I said, unless they're in a rural area where there's maybe not a surgeon in town or, yes, completely agree. Right. Okay. And then you talked about the high risk sites for oral cancer. What about patients that use, alcoholic mouthwash. Does that increase the risk? So it's interesting. So there is a synergistic effect between tobacco and alcohol associated with oral cancer. I always tell my patients to avoid using alcoholic mouthwashers. They say, you know, if you want alcohol, put it in your cocktail, right? Don't waste it on rinsing your oral mucosa. Just swishing it around in your mouth, you're exposing the soft tissue to the alcohol for a longer period of time than just chugging. you know, a single malt scotch or something. Yeah. Although wine, you're supposed to do all those S's, right? Swirl, smell. I don't remember all of them, but I forgot. I haven't been on a wine testing tour for quite a while. The typical oral cancer exam, because that's what GPs do. I mean, that's something that's in their wheelhouse. So could you give us a brief overview of the typical oral cancer exam? And are there any adjuncts that you can talk about that would help a GP identify something that looks... aggressive or abnormal yeah so i mean the basic exam is um initially just kind of a gross assessment, looking for any asymmetry, any abnormalities, checking the skin, checking the eyes, just a general exam, right, after you've obviously done your history taking. Then I would say focusing on muscle palpation as well as lymph nodes and obviously checking range of motion of the TMJ. Do they have any limited range of motion? Check the salivary glands. Then intraorally, you obviously want to focus on all the soft tissue, focus on the salivary glands, whatever, pull the tongue out, look in the back of the throat, lift the tongue up, feel the floor of the mouth with bimanual palpation, as well as feeling the lips bimanually. Whatever you do, I think it's really important to always go in a systematic way so that you don't miss anything. And then basically you become kind of like robotic, which is, I actually think is good because then you just won't miss it, right? It just becomes second nature. In terms of adjunctive aids, there are a bunch on the market. um in terms of cell fluorescence such as goggles which i had mentioned in my lecture which basically works by the natural autofluorescence of cells so you wear the goggles or goggles and they're green the screen and um or the lenses excuse me are green and then you use a blue curing light which is in the range of like 380 to 500 nanometers and basically The way it works is that the abnormal tissue will look dark and the healthier normal tissue will just look normal. And it's because the abnormal tissue has less fluorophores because there is a disruption in terms of a lot of the collagen has been disrupted and there's also a different nuclei to cytoplasm ratio. And given that information, there's an increased absorption of scattering and that's why the tissues look dark as opposed to looking. As opposed to the light just bouncing back at you or reflecting. So that's actually sounds interesting because the goggles, what I've heard about that, it's, I mean, it's very mobile because you just put, you can go into any operatory. They all have curing, every operatory has a curing light. You just put the goggles on, you can move from operatory to operatory, I guess. Right. And use it. So, and that's useful in seeing something that would just alert you to say, let's investigate this further or is it? could be somewhat definitive. At this moment in time, nothing replaces using your eyes and your hands and manual palpation. I think that this can help as an additional. thing to kind of say like okay wait I didn't see that before now I see that let me investigate this further uh and then go from there and then you basically take the goggles off again and say wait did that look like something oh it does look something I didn't even see that that was a white spot um maybe that's a leukoplakia maybe that's something else I guess we should explore it further or you might see something and say oh wait no so I think you always have to kind of verify But it's kind of like an extra, it's an extra feature basically. Yeah, that makes total sense. And if you could find a tool that is mobile from one operator or the other that can actually do this and save a patient's life, certainly that's worth looking into. Yeah. And Gockels is sold through a company called Perel Pharma. I'm talking to our audience now. So it's funny to say Google Gockels, but Gockels, I think is spelled G-O-C-C-L-E -S. Does that sound right? Yes. Okay. And that is in your webinar. So we did get some of that information from your webinar. So for the new dentist that's coming out of school, do you think they're spending the time to carefully do an oral cancer exam, knowing that they're eager to get into the restorative work and get the crown and bridge going and all that other stuff? What's your thoughts on that? Unfortunately, I think it depends on the type of practice that you're in and the type of office. But I think if it's very high volume, you just graduated from dental school, you have a lot of loans, it could be tempting to skip out on this part. And it also, unfortunately, I mean, it's more lucrative to do a restoration or a root canal or something than it is to do an oral cancer exam. But obviously, the oral cancer exam. At the end of the day, that's really saving someone's life. And I mean, arguably, I guess you're saving someone's life. It's also with a root canal, if God forbid they could get an infection. But it doesn't take that long. Each time that the patient has a hygiene visit, even if you're busy, that it's really important to just do this exam. Should the hygienist be doing it? I don't see why not. Yeah, for sure. I mean, I think if you feel comfortable that the hygienist and the hygienist feels comfortable doing it, then they do a thorough exam as long as the patient's getting the exam. Yeah. What is the what's the time frame that you're talking about as far as a complete manual visual exam, whether using goggles or not, or any other? There's other devices out there as well. How much time do we think we're talking about to do on a typical patient? I mean, I don't really think it takes that long. I would say five minutes max, because, you know, you get into you get into the rhythm of what you're doing, asking them questions and then. doing the gross examination looking inside. I think if you use an adjunct V, sure, it'll take a little bit longer, but it might actually in some ways help in terms of making the practice like, oh, wow, they even use this light. They're really checking thoroughly. I feel more comfortable. I think for patients, like I said, you don't want to use the adjunct V. loan, you definitely have to do your exam and then you use it and then you kind of verify it back. Yeah. And early detection from the standpoint of saving lives statistically, isn't that huge getting oral cancer early? Because doesn't oral cancer have a fairly poor prognosis if picked up late? Yes. And unfortunately, it's usually picked up late. Like 50% are picked up at like stage four. It is because sometimes it's very hard to find. A lot of times the base of tongue, we cannot see that. But in every other area, there's no reason that we cannot find it. We should be looking. If you feel when you do a bimanual palpation on the floor of the mouth or the tongue, and if you feel an induration or some sort of asymmetrical mass there, even if it's small. that even if you can't see anything, you don't see anything with the goggles, is that something that you should alert the patient or go to the next step? Absolutely. So, so there are cases where it could be really hidden and it's not visual, but you can feel it. Yes, for sure. Okay. I mean, there's a lot of times there are patients that, or you'll just maybe feel it with a lymph node. I mean, a lot of patients I've seen that have like recently been diagnosed, they'll say, you know, I just noticed a lump on my neck while I was shaving. So they noticed the lump on their neck while they were shaving, but you could have easily. felt that too while you were doing your exam. Yeah. That's, that's really scary that the prognosis drops and you're saying that 50% are, did you say our fourth stage? Yeah. And what's the prognosis for fourth stage? It depends on the type of cancer. Yeah. But it's not great. It's not great. Yeah. It's not great. Like less than five years or something. Yeah. It's really, when I hear the stats on oral cancer and how many people die from it, it's remarkable because you think that people would notice something in their mouth even before they, if they don't go to the dentist that often. they themselves would feel something abnormal. Obviously, a lot of it's asymptomatic. Exactly. That's the scary part is that it is asymptomatic, so they don't know. And the mouth is not so easy to see, so unless they're really looking in there, patients are not going to even know this. Hopefully, dentists will be a little bit incentivized by this discussion to be extremely meticulous in the first five minutes of their appointments, and I think it's a practice builder. I mean, like you said, a five-minute oral cancer exam could be something that the patient could tell their friends and family about and say, wow, this is the first time I've ever had a really comprehensive oral cancer exam at the dentist. The dentist really cares. And it is a billable procedure, though, to some extent, isn't it? Yeah. All right. Well, I appreciate your feedback, Dr. Levi, and thank you very much. Have a great day. Stay safe in New York. I know New York's doing better. We're in Texas, and we had a spike, and now we're... a little bit better. So hopefully this, within the next six months, a lot of this will be behind us. That's what we have to pray for. Anyway, thank you very much, Dr. Levi. Appreciate your time. Thanks so much for having me.