Collaborating for Oral Health
By CAROL LATTER / Photography by Connecticut Headshots
The UConn School of Dental Medicine teaches new providers while treating and educating patients with pain, dysfunction, cancer, and more
For most people seeking oral care, the issue involves nothing more serious than a semi-annual cleaning, a cavity, a canker sore, or crowded, chipped or crooked teeth. But for some, there’s a more serious matter at play – such as chronic pain, infection, or even mouth cancer, requiring assessment and treatment by experts. The challenge lies in identifying those problems early and getting patients the care they need in a timely way.
In Connecticut, help is close at hand. For nearly 50 years, the UConn School of Dental Medicine (SDM) in Farmington has been a national and even international center of expertise. In addition to offering world-class care to patients, its faculty members conduct groundbreaking research and share their wealth of knowledge with both longtime colleagues and those new to the field.
Dr. Ellen Eisenberg, DMD, now in her forty-first year at the dental school, is an oral and maxillofacial pathologist and professor specializing in maxillofacial conditions – diseases, defects, injuries, and other pathological issues involving the mouth, teeth, jaws and face. This specialty involves diagnosing pathology at both the clinical and microscopic levels, as well as teaching students and treating patients experiencing a spectrum of oral mucosal diseases as well as cancer, dysfunction and pain. “As diagnostic specialists, we are not doing typical dental procedures,” she says.
In addition to training UConn’s own dental and medical students to diagnose and treat conditions involving the mouth and surrounding structures, the school’s professors provide outreach to students in local dental hygiene programs, teaching them what concerning signs to look for and bring to the dentist’s attention.
Dr. Eisenberg notes, “We emphasize the who, what, where, why and how of oral cancer – how it develops, how it looks, who is more likely to get it than somebody else, and where you’re likely to find it in the mouth. We help providers know what to do next if they find something suspicious.”
Dr. Easwar Natarajan, BDS, DMSc, an oral and maxillofacial pathologist and member of the team for the past 15 years, says this training gives providers the ability to thoroughly assess a patient’s mouth during every dental cleaning, checkup or procedure – or during a doctor’s visit for unusual oral symptoms like bleeding, swelling, sores, lumps, or white spots. Prompt diagnosis and treatment are key to better patient outcomes.
“All it takes is 60 to 90 seconds of good examination of the oral soft tissues,” Dr. Natarajan says. “It doesn’t require a special test. It doesn’t require a special technique, or a special fee, for that matter. That’s something that we are all passionate about and believe really strongly, that a patient shouldn’t be charged for an oral cancer screening. It should be part of every routine oral examination.”
Oral cancer is all too common
The American Cancer Society estimates that about 53,260 Americans will get oral cavity and oropharyngeal cancer in 2020, and about one-fifth will die from it. Oral cancer is slightly more common in men than in women. On average, people are 62 when they’re diagnosed with oral cavity cancer, but younger people can also be affected. Major risk factors for oral cavity cancer include tobacco products, says Dr. Eisenberg, “but we also see cancer from time to time in patients who’ve never been exposed to tobacco.” The biggest driver is genetic susceptibility, but science hasn’t yet identified the genes responsible so it’s important that everyone be screened.
Patients should not automatically suspect the worst if they notice an unexpected change in their mouth. Pain, swelling or bleeding is usually caused by something simple, like irritation from the incisors, a faulty dental restoration, a broken prosthesis, or an overly hot or abrasive food. That said, notes Dr. Douglas Peterson, DMD, PhD, FDS RCSEd, an oral medicine professor at UConn for the past 30 years, “If you have a change in your mouth and it’s persisting more than a few days, you should consider being evaluated by the dentist. It doesn’t mean you have cancer, but it certainly warrants follow-up. That’s important.”
Identifying a problem
Many people don’t realize that making regular visits to their dentist can not only help patients maintain good oral hygiene and prevent decay, but identify serious conditions that may impact their overall health, or even their life. “A majority of the patients that we see as oral pathologists are referred in from the outside, by other dentists, dental specialists, and physicians of one sort or another, including medical specialists for a variety of problems that can present in the oral cavity that are not necessarily related to teeth and the periodontal structures. So we see a range of pathological processes, which we diagnose and, in many cases, we continue to manage or treat,” Dr. Eisenberg says. A patient can also call the dental school directly.
Symptoms and findings vary. One common presentation, says Dr. Natarajan, is “a white patch, typically along the sides of the tongue, under the tongue, or on the floor of the mouth.” A discoloration might also be red. There can be a change in texture, a lump, or an open sore on the tongue. A dentist may correct any abrasive surfaces in the mouth to see if that solves the problem. “If not, they would send the patient to an oral surgeon – or there are dentists who do the biopsy themselves in the clinic and send it out to us.”
Dr. Eisenberg is quick to reassure patients that mouth trauma does not cause cancer. But she notes that a patient who has already had a precancerous condition or a cancerous lesion is “at particular risk for developing another.”
Treatment and recovery
Patients diagnosed with cancer at UConn Health receive state-of-the-art treatment, which may include surgery, radiation and/or chemotherapy. While these treatments can be extremely effective, they can lead to other debilitating problems. That’s where Dr. Peterson and colleague Dr. Rajesh V. Lalla, DDS, PhD come in, working “side by side” to provide supportive patient care.
Dr. Peterson says most oral cancer patients are older adults, and many have limited access to healthcare, so by the time they’re diagnosed, the cancer is likely at a moderate to advanced stage. Such patients often require “a very physically and psychologically demanding cancer treatment.” The supportive care team is tasked with ensuring the patient is in the best possible condition before that treatment begins.
Dr. Lalla explains that most patients receive high-dose radiation therapy, which can lead to significant mouth complications, both during cancer treatment and long afterwards. “If we extract a tooth in someone who has previously had head and neck radiation, the site may not heal properly and may result in osteoradionecrosis,” or bone death, he says. “Before starting radiation therapy, we assess and treat their dental conditions so that we can avoid doing extractions on these patients after radiation therapy.” If patients have co-existing medical conditions, these must be taken into consideration as well.
The supportive care team also does everything it can to help patients ward off adverse effects from radiation treatment – such as oral mucositis, in which patients develop severe mouth ulcerations, can’t eat by mouth, and have to be fed through a stomach tube. They may require opioid pain medications and, in some cases, may need to be hospitalized. And since high-dose radiation of the head and neck affects the salivary glands, patients can end up with a permanent reduction in salivary flow, causing dry mouth. This, in turn, increases their risk for dental cavities and gum disease over time.
Dr. Peterson says that the SDM offers patients the full spectrum of care, “from cancer prevention to early diagnosis and treatment, to prevention of the sometimes devastating side effects that these patients might otherwise experience.”
Because the vast majority of oral cavity cancers are caused by tobacco products, with damage accumulating over time, SDM faculty collaborate with other UConn providers, through interprofessional education, to advise their patients not to smoke – or if they do smoke, to join the UConn Cancer Center’s tobacco cessation program. “If people don’t smoke, the odds of getting oral cavity cancer are very, very low,” says Dr. Peterson. Patients should also be aware that alcohol – even mild to moderate social drinking – can increase their risk of developing cancer.
Another important part of the SDM’s care program involves chronic pain issues. Dr. Seema Kurup, MDS, MS, FAAOM, says her primary focus is diagnosing orofacial pain that does not necessarily stem from the teeth but instead may involve other parts of the head and neck.
“I see those cases where providers are not able to pinpoint the cause. Patients may doctor shop and eventually end up on multiple medications. Most of these patients have a poor quality of life. There’s often a huge component of depression, anxiety and stress in these patients when they come in.” Dr. Kurup addresses both the physical and mental aspects of pain to increase patients’ wellbeing.
She says orofacial pain can have many causes, including microscopic trauma from clenching, grinding or frequent gum chewing; neuropathic or neurovascular issues; poor posture; and vehicle accidents that cause whiplash or other injuries.
Sometimes, pain in one area can “refer,” or transfer, to another. For instance, someone who works for long hours hunched over a computer may end up with jaw pain, or someone with a shoulder cramp may develop chronic headaches. It’s Dr. Kurup’s job to find, and treat, the root cause.
Often, she says, patients suffer unknowingly from temporomandibular disorders involving this joint connecting the jaw to the skull bones. Left untreated, patients may reach a point where “they’re not able to open their mouth or talk or eat.”
Pain can also be related to ongoing stress or difficulty sleeping, which can intensify a patient’s perception of painful symptoms. In cases where the pain is caused by metastatic cancer, Dr. Kurup will investigate and diagnose that, then refer the patient for treatment.
Treatments for noncancerous conditions may run the gamut from things like heat, ice and physical therapy to pain medication, topical ointments, Botox, laser therapy and ultrasound treatments. Meeting with a psychologist or social worker can also be tremendously helpful.
“There’s a host of management options out there,” says Dr. Kurup. “It’s not one size fits all. It’s very, very customized to the patient, depending on what their background is, how they are emotionally, whether they have other systemic complaints, all of that.” She says chronic pain isn’t usually due to one cause.
For people unable to visit UConn, or who are patients of other healthcare systems, Dr. Kurup regularly participates in e-consults to help chronic pain patients, and their physicians, get to the bottom of it. “You can also have the UConn dental faculty sit in on those e-consults and deliver appropriate management techniques, which is really convenient,” she says.
Dr. Kurup is very excited about the proposed Connecticut Comprehensive Pain Center at UConn. “The plan is to have a place where patients can come and be evaluated by a multi-disciplinary team who all have interest in treating pain. The team will create realistic goals for function and with whatever modes we have available.” The center will also address pain mitigation, helping patients affected, or potentially affected, by the opioid crisis. “This will be a very unique, UConn-centric facility,” she says.
Dr. Kurup’s work is closely intertwined with that of her colleagues. Among other collaborative efforts, she directs a course for dental students on orofacial pain and is involved in the outreach to dental hygiene students. “I think it’s important that I’m teaching future dentists, because they’re the ones who are going to go into the community and interact with patients. And one of the things I tell my students is to just spend more time with the patients, that empathy needs to come into it, and that’s what we’re doing here.”
Continuous improvement of care
The UConn School of Dental Medicine is constantly trying to raise the bar when it comes to oral diagnosis and treatment. The combined dental and medical curriculum integrates the latest science into clinical practice and provides interprofessional education in collaboration with everyone from nursing and pharmacy students to social workers and the hospital chaplain. “We do case-based teaching with the interprofessional students to really prepare them for these very complex clinical issues down the road, so the teaching is integrated in very powerful ways. We’re not the only academic health center that does this in the country, but we’re one of the precious few,” says Dr. Peterson. “It’s really a signature piece of our program here.”
The school as a whole is extremely well-respected, far beyond Connecticut’s borders. For the past 45 years, UConn has operated an oral pathology biopsy service, currently directed by Dr. Eisenberg, that’s used by oral surgeons and other providers throughout New England and across the country. “I’d say that is a unique feather in the cap of UConn Health that sometimes flies under the radar,” says Dr. Natarajan. Dr. Eisenberg and Dr. Natarajan diagnose roughly 4,000 biopsy specimens annually.
Various faculty members are also involved in research studies – many funded by the National Institutes of Health – to identify and test innovative diagnostic and treatment tools, and to research the side effects of cancer treatments.
Team members are also involved with lecturing and developing clinical practice guidelines at the national and international levels, as well as heading up and participating in a variety of respected organizations like the American Academy for Oral and Maxillofacial Pathology, the Multinational Association for Supportive Care in Cancer, the American Academy of Orofacial Pain, and the American Society of Clinical Oncology. Through their involvement, says Dr. Peterson, “the role of dental medicine in oncology management is being communicated around the world.”
He says UConn’s program is unique – not only for what it brings to UConn Health, but to the state and beyond.
“We’re very proud of what we do,” Dr. Peterson says, “but we’re not alone in this. We have the strong support of our colleagues in the school, as well as the support of the interprofessional oncology team here at UConn Health.”
Carol Latter is Seasons Magazines editor and a freelance writer living in Simsbury.
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