Dentist⁠, Laila Akhlaghi, D.D.S.

0:01 Hi, it's Doctor Robert Seikard with episode #19 of Doctor Podcast. Thanks for tuning in and watching again today. I'm pleased to have as my guest Doctor Leila Aklagi. Dr. Aklagi is a dentist. She's on the faculty at the well known Presbyterian Medical Center, Columbia Presbyterian Medical Center here in New York City, which is one of the top hospitals in the entire country. And Doctor Aklagi is in the dentistry department as well as in the oral surgery department. What I'd like to discuss today is a very important topic that does not get enough mention and people don't know about it.

0:42 Even though as an ophthalmologist I have patients with lots of dental and mouth issues and sometimes they don't know where to go to get that taken care of. And today, I'd like to specifically discuss some of the problems that patients have who have cancer or on chemotherapy or getting radiation and what types of dental and mouth problems they get. So thank you very much for coming today. Thank you so much for. Having me, I appreciate it. Thanks very much. How did you get interested in dentistry and and how did you get involved in that?

1:17 Well, I always knew I was going to be in the medical field, but I always liked sort of the the artistic aspect of dentistry. So that's why I wanted to combine medicine and dentistry together, because I like working with my hands even from a young age. So that's how I got into dentistry. But the actual oncology side of things is another story. And that began with I think I was a resident and my mom was diagnosed with breast cancer, metastatic breast cancer. And she obviously needed quite a bit of dentistry down at the time.

1:51 And we all found it quite difficult finding her the care that she needed. Despite the fact that her daughter was a dentist, we were finding it difficult to get that exact care that she needs. So that's the path that got me interested in doing oncology dentistry. And eventually I married a oncologist, pediatric oncologist. So it became my area of passion, expertise and I felt like it was something that it was not enough attention was given to it, so that's how I got into it. How do people who have dental and mouth problems and they're getting chemotherapy or they they have cancer, they may get radiation around the upper part of their body.

2:38 How do they find somebody like you who specializes in this and can help? Them out. So currently I would say the academic institutes that have incorporated multidisciplinary team including dental within their patient services would be the the, the institutes that cover oncology dentistry and luckily at Columbia University Urban Medical Centre, dentistry is actually a a part of all patient. It's like everyone has access to dental needs for for all patients. So it I would say it's mainly the academic institutes that have incorporated.

3:20 So unfortunately not that many but the ones who have provided great service for patients and for example because we are part of the oral surgery department, we are available to patients even 24 hours the service is always available. So if the medical or the oncology team expects immediate attention for a dental need, it's available which is quite nice because it's been incorporated into the care for patients. And you know obviously you know we will discuss the problem in a bit, but dental clearances is what is the key issue that oncology patients specifically head and neck patients need and is always a race for time because by the time they get diagnosed they need the dental clearance and they're trying to do everything else.

4:20 So it's good to have this service available at the hospital, which is very valuable to patients. Right. So let's say a patient has cancer and they're about to get chemotherapy. You evaluate them ahead of time. So the issue is in an ideal scenario, you would want to evaluate every single patient who is about to receive chemotherapy. However, because of the large volumes, not everybody necessarily needs dental clearance. Dental clearance is more focused for patients who are either going to get head and neck radiation or for patients who are about to receive bone modifying medication like denosumab or zolidronic acid, any of the bisphosphonate groups because of the long term effects that it has on the jaw.

5:14 So it's mainly the metastatic cancers that will require dental clearance along with the head and neck because of the radiation and the bone marrow transplant, pediatric and adults. So these are the main groups. So can you explain how radiation causes problems in the mouth and and in dentistry? Yes. So radiation to the head and neck area obviously has quite a profound effect on the dentition as a whole. So the first thing that patients experience is that they have reduced saliva and because of the lack of salivary flow, they have issues with swallowing, with eating, with chewing, with speech.

5:58 So the dryness, the rostromia is one of the main issues and that itself also increases the risk of dental complications in the future because obviously saliva remineralizes teeth and if you have reduction in salivary flow, then you will have less mineralization. So you at a much higher risk of getting dental decay. So that's one issue, the other. Issue Let me let me ask you this, the there are glands in the mouth, right? Salivary glands that produce your saliva and keep your mouth wet. Yes, the radiation damages those glands and.

6:33 So the the we have minor and major salivary glands in your oral cavity and they all get affected even though that with the new planning of the radiation, they try to avoid hitting the salivary glands as much as they can. It's just sometimes it depends where the tumour is. Sometimes the head and neck tumours are within the salivary gland, so you will actually have to surgically remove and radiate the area. So the head. And when we talk about head and neck cancer, it's not specific, always in the same location.

7:07 So it depends on where the cancer is and often they all do end up with dryness, which is a side effect. So again, there are high risk of dental decay, high risk of periodontal issues because the gums dry up. So that's the long term issues. The immediate effects is normally pain due to mucositis and. That's a common word I hear from my patients who are getting chemotherapy or radiation. Can you explain what mucositis is? Mucositis obviously in head and neck mainly happens in the oral cavity. But for cancer specific cancer patients, it can happen anywhere within the GI tract and it's basically in simple terms breakdown of the oral mucosa in terms of forming ulcers.

7:53 And that's because either because of the radiation or the chemo, there's damage to the cell proliferation. So it breaks down and then mucosa gets very thin and ulcers form. So it's it looks like a typical ulcer, but it's just because it's of the damage of the DNA of the cell, especially the mucosal layer and it causes mucositis. But the good news with mucositis is that it's self limiting so it results on its own within two weeks roughly it appears I would say around 7 to 10 days after either exposure to specific type of chemotherapy drugs or after getting head and neck radiation.

8:38 But it's self resolving so it goes within two weeks. However, one thing that I would like to reiterate on is that sometimes these areas get secondary infected, either with bacterial, viral or fungal infections. And that's when it's important to actually monitor to see how long it's taking for the ulcers to heal up. And if it's longer than the expected period, that's when we come in and we want to have a look, maybe take a swab, take a culture, just to make sure it's not secondary infected. Right.

9:10 And the ulcers are very painful also. They all very tell me they. Yes, they are very painful, yes, because it's like a breakdown within the mucosa. So it's very so and depending on the level, sometimes it affects their ability to even eat or drink and it in, in severe cases they will actually need to receive IV either fluid or in cases where they're going to have prolonged ulceration in some of the stem cell transplant patients they end up sometimes with feeding tubes and that's specifically quite challenging.

9:49 But you know, like it's one of those things that are we trying to cure the disease as a whole, and this is one of the unpleasant side effects. Right, I've heard some of my patients take something called Magic Mouse Watch. Yes, Magic Mouse Watch tell. Me. What's magical about it? Why they call it that? It just contains lidocaine, so it contains topical, so it's a mixture, and it contains topical local anaesthetic, so they feel numb. So it just is an anaesthetic, yes. So it just numbs the area. Yeah.

10:22 So it has some, they mix it with different formulas and sometimes it's got anti-inflammatory because you know the whole ulceration is because of inflammation. So the combination will help, but doesn't really resolve the problem right? It just helps. It and actually just I just want to mention that as as part of being within the cancer centre and the oral surgery department at Columbia University, we're trying to find ways to help patients or prevent or actually treat mucositis. So the duration is shorter.

10:59 So we're looking into using low laser, low level laser therapy to deliver at the time of either expecting mucositis or when they already have mucositis to help them heal faster. So this is a very interesting way that we're trying to help our patients. So the lasers help the ulcers heal. Yes, because it has analgesic effects as anti-inflammatory effects and also it allows the fibroblasts to lay cells faster so they can recover so healing purposes. So this is a low level laser, not obviously the the type of laser that we do for surgeries.

11:41 This is just energy. Right, there are different types of lasers. Like photobiomodulation, that's the actual proper term that I should be using because it's you're delivering energy to heal up the the areas, which is something very exciting. Right now since you're at the Medical Center there, there's a lot of patients that are obviously being treated, yes. Do the oncologists and the the chemotherapy and radiation oncology teams contact you for every patient or how does how does the patient get to see you?

12:13 So as we were discussing earlier, so the dental clearances has been incorporated as part of the service within the different teams, especially the head and neck team and the bone marrow transplant team, paediatrics and adults. And for hemog group, as you know hematology and oncology and for patients who have metastatic either breast, prostate, lung within any bone metastases. So because they know we provide such a service as soon as the patient is diagnosed or as soon as they require receiving bone modifying medication, they reach out And we have a on call team that can take care of it if it's really urgent within 24/7.

13:02 So it's literally available all the time or we could arrange if it as an outpatient. So they come to me directly as an outpatient. So exactly. You know, sometimes there are cases that, you know, they want to start radiation as soon as possible and it's, I don't know, middle of the night. So that's when actually all residents get called in and the oral surgery department takes care of that. That's great. But this probably only available in major medical centers. I would think some of the smaller community hospitals probably don't have this.

13:39 So it's advantageous for patients to go to major medical centers like Columbia. Presbyterian, yes, It's very advantageous because you know our services available to our patients and also we take patients from outside because sometimes you know they cannot find a dentist or service that can provide them clearances because not everyone's even comfortable, not all the dentists are comfortable providing. So patients who were being treated, let's say in a Community Hospital where they don't have the service can make an.

14:12 Appointment to see you and then you can. Treat them as an outpatient while they're getting chemo and radiation. Well that's that's great to know. Yes, I I don't think that's really marketed or advertised. I I just feel like it was, as I said, because of my personal experience. It it just, it became my area of passion because I felt like they're going through so much, whether it's head and neck or systemic, different types of they just need that service. And it's more than just, you know, doing a routine dental exam.

14:51 It's a lot more than that. So I I do feel it needs to be out there more. I agree. Yeah. What kind of steps and measures can patients take on their own at home, let's say, to keep their teeth healthy, their mouth healthy, while they're getting this? Yes. So as patients who've experienced chemotherapy and cancer, they know that the diet becomes an issue. So a lot of times they cannot either eat or they feel sick and they have, you know, vomiting and because of that the acid destroys their teeth as well.

15:30 So one thing that patients can do, obviously having regular dental visits and check ups and cleaning, which is sort of like the preventative measure, is something that they can do. But at home they should reduce sugar intake, carbonated, anything that can cause decay, because they may feel that they crave sugar and they just want to have sugary drinks or sugar, but that can actually have quite a lot of damage to the teeth. So it's monitoring your diet. So that's. Not how does sugar damage the teeth.

16:01 Can you? Explain that? Sure. So as soon as sugar or anything that can be any extrinsic sugar is in contact with teeth surface, the bacteria that live within our mouth, normal flora start getting activated and they produce acid. That acid will cause erosion of the enamel and that will cause dental decay, which is a dental infection. So we we talk about the decay as if it's like a separate entity, but dental decays infection of your enamel and your dentin and that's because the bacteria starts eating up your teeth if you like by producing acid.

16:47 So essentially and without that sugar they cannot do that, so they need the sugar and This is why sugar intake is quite an important factor to take into consideration. So. The bacteria eat the sugar that you're putting in your mouth and then they produce an acid and. Studies have shown that the acid is the pH in in your oral flora just drops and it stays below. It becomes quite acidic up to even 60 minutes after each sugar exposure. So frequency of sugar exposure becomes another issue. So I often tell my patients, you know, you know how we would say, oh, don't finish all your all your snacks in one go, just that's the worst thing you could do.

17:35 So is reducing the frequency of exposure to sugar also that will reduce? So does rinsing your mouth with water or mouthwash after, let's say you can't resist those doughnuts or the ice cream. So is there anything you can do? Evidence actually shows that you can easily tolerate 3 or 4 exposures to sugar per day and your body and your saliva re mineralises your teeth. So it's not that you can never have any form of sugar, it's just the frequency. If you start having snacks throughout the whole day and the sugary snacks, that's when the balance tips towards becoming decay.

18:15 So reducing sugar intake, reducing the frequency of sugar exposure and on top also increasing fluoride application, which is absolutely the IT literally counterbalances all the stuff that the sugar does, fluoride. So fluoride is in toothpaste and the state of New York is in your water which is great cuz as you having water you're getting some exposure to fluoride and also dentists can apply fluoride varnish every time you actually go to the dentist. And in our patients because there's such high risk for complications we often prescribe the high dose fluoride toothpaste called predator and that is especially head and neck.

19:03 You know we were discussing how they don't have saliva that will re minimalizes the teeth. So it it helps if if, if you like a kind of vitamin for your teeth, right? Let's put it like that. That's how I always explain it to patients, right? There's a product called MI Paste which I believe has fluoride in it too. Yes. So and yes it is anything that's got fluoride in it. So what we tell patients is that you know even after you use the fluoride, don't rinse with water, just spit it out and let the fluoride out exactly.

19:39 That's another thing. So you know you could the sugar. We've talked about reducing the frequency, healthier choices for diet and fluoride use. So I often even prescribe A fluoride mouthwash and tell patients you know. Ideally you should be brushing twice a day anyway, which is morning and night time, but you know, mid-day if you're somewhere and you you just had like lunch. Why don't you just do a fluoride rinse afterwards so that will increase your fluoride? Is that a higher concentration in what's available over the counter?

20:11 The ones that we prescribe to patients, yes and is only prescription, but any like any toothpaste that you buy from the big brands, they all have the adequate dose of fluoride. What about xylitol, right? Does that help? Well that will increase your what is as you know it's a sugar substitute so it doesn't damage your teeth and what it does it increases your salivary flow so you encouraging the saliva to re mineralize teeth. So yes, it does help for sure. Yeah, they have Xylitol gums, yes. Yes, and sugar free gums is actually quite useful in increasing salivary flow and sometimes we even advise head patients to use sugar free sort of like sweets to improve salivary flow.

21:05 The more saliva, the better. Exactly, yeah. Because your saliva is full of minerals, so you you're kind of remanalizing and teeth don't like to be dehydrated, right? Because yeah. Is there any value with rinsing with hydrogen peroxide, the 3% that you can buy over the counter right that's killed the bacteria that are produced so? You do have some anaerobes in the mouth, and anaerobes are mainly, as you know, they thrive in environments where there's no oxygen, but they're not necessarily the ones that cause decay, They're the ones who cause gum problems and they live in their pockets.

21:43 So yes, that's a very useful mouthwash, but mainly in patients who have deep pockets like IE periodontal issue, gingivitis issues that they cannot reach or clean. So that's something that we recommend for patients with deep pocket because of the arrows, but it doesn't help with decay. Oh, it doesn't. It doesn't get rid of the bacteria that produce. The acid not necessarily, it's just because of the oxygen, it just helps it. It's more for the gums. So yes, it's useful, but in a different way. That's that's good to know.

22:22 Can you explain the importance of early intervention in in these patients as opposed to waiting till you've got a bad problem? Yes. So early intervention is key and the reason is because when we meet our patients, we have a baseline. So we are able to look at their teeth, evaluate their needs, take necessary X-rays, which is very important. Sometimes you have things that you didn't even know about impacted teeth or even cystic lesions that you didn't even know about. So it's important to be able to diagnose it as a baseline and pre treatment especially in head and neck and the bone modifying medication patients who have more metastases or even breast cancer patients.

23:14 So as a result, we are able to actually do all the minor surgical procedures before they start the the, the treatment that can affect their jaw. And the reason is because if you do not do the surgical procedures or the extractions or whatever they need and they do start with radiation afterwards, you're putting your patient at a high risk of getting something known as osteoradionecrosis or bisphosphonate related osteonecrosis. And that's very difficult and challenging to treat because often it interferes with their treatment.

23:55 Even so, they need to get delayed treatment. They may not heal. It's very painful. It's not a fun thing to fix at all. So we want to avoid that, right? Yes. So that will stop it. You mentioned osteonecrosis. Can you explain what that is in in terms? Of yes Osteonecrosis is when you the bone within your either Mandible or Maxillogist. You know in the in the maxilla is the upper part of the jaw and mandible is the lower part and the bone just becomes necrotic so it uses blood supply and it just becomes unfortunate like a dead bone.

24:34 So osteonecrosis is dead bone and body obviously does not like having any dead tissue in it. So it starts rejecting it. And because of that patients often get pain and there's inflammation and sometimes it gets secondary infected with pus. And it becomes like a whole problem because the more you try to remove it, the kind of more it spreads because. And that's because of the type of medication they've either received to to to treat the cancer from spreading in the bone like the Brankel inhibitors and denosumab for multiple myeloma patients or you know, like any of the human patients that need it.

25:19 So they need that to stop the cancer from being so aggressive. But at the same time it becomes, yes. Yeah, so that's what it is. It's just dead bone. Right. Related to that, not in cancer patients, but some of my patients, especially postmenopausal women, are getting treatments for osteoporosis and a few of them have told me that they've developed that jaw necrosis. Oh. Yes, it's very why does that happen. So again, in an ideal sort of scenario you even want to do a dental clearance on your patients before they start taking medication for osteoporosis.

25:59 However, the doses are completely different. I see because the the for osteoporosis, they get either an injection or they take tablets depending on what the doctor prescribes either every six months and the dose is normally like around 60 milligrams. Whereas for cancer patients like for example, I'll give you one of the multiple myeloma, they get 120 milligrams every three weeks or every four weeks depending obviously what regimen the oncology decides, but it's much higher dose. So the chances of things going wrong is much higher in cancer patients.

26:40 And for for the osteoporotic patients, we often even plan it with the MD's and say, you know, we want to do an extraction, can this patient miss a dose? And then we plan to do the extraction towards the end of the cycle where they had received the medication. And we try to do it as a traumatic as possible. We give them antibiotics, we've got a protocol that we follow and we haven't had really major issues with that because we've learned how to deal with it. Whereas with the cancer patients, you know they need it much more and much higher dose.

27:22 So that's when it becomes an issue and the longer they're on the medication for the cancer treatment, the worse it is in terms of risk. Right. As part of going back to the dental hygiene a little bit, does flossing help also in preventing problems? Yes, So obviously when you brush your teeth you clean the surfaces that you can reach and the into dental area which is where your teeth come together is always going to get missed by the brush because the brush cannot get into it. So flossing or into dental brushing whether you know I don't know if anyone has used the new silicone based ones which is quite easy to use and quite user friendly.

28:06 So you will be cleaning those areas that you cannot reach with with the toothbrush and obviously. Good for everybody. Yes, everybody. Everybody should brush and floss every day. But for cancer patients, they often get scared because they bleed because either you know, they're vet and you compromise or they're on some regimen that you know they they bleed or from cytopenia or something. So they bleed and yeah, so because of that they bleed and they get worried. Obviously we're not encouraging aggressive into dental cleaning, but flossing which is quite easy to and you know as part of the prevention we show patients how to floss because often patients just put the floss in and take it out where it's like the gum is kind of triangular.

28:58 So you want to clean not the top part, you want to clean the contact points between the teeth. So flossing itself it's like a a specific. Way that you can be trained how to floss. Yes, it's that's exactly why you know having the adequate oral hygiene regimen will help with patients because you can't just push it in, it has to be like cleaned in between. So there's a specific. Way on that topic, Are electric toothbrushes better than just manual hand toothbrushes? I believe so, yes. And the reason?

29:32 Not every single electric brush, but the ones that have got the Sonic movement, they will actually help tremendously because they break down the plaque because plaque forms within 12 to 24 hours after sight has not been cleaned. Can you? Explain what plaque is. I hear that all the time. What is plaque? It's like a biofilm. So as we discussed, your mouth has quite a lot of bacteria and that's your normal flora. So if a a sight of a tooth has not been cleaned between for 2012 to 24 hours, a biofilm starts forming.

30:08 That's from the bacteria, yes. And the food, you know, the food, everything is in your mouth. So a little biofilm forms. And then that's why we encourage twice a day brushing because then you're removing the biofilm. Now if that biofilm is not removed, what will happen is with the saliva, it starts getting calcified and with time it almost looks like limescale. You know, patients who have calculus, which is like limescale. It's the biofilm that has become calcified because of the saliva and the lack of adequate cleaning.

30:47 So it becomes like this limescale. It's. Hard. Yes. And there's. No way. Film that attracts calcium. Yes, it's almost like bone. Exactly. And it you cannot remove it. You need professional intervention, either by your hygienist or by your dentist or your paradontist, because you cannot remove it. It's quite difficult to remove. It's like glitchy limescale. And that becomes like a yes, and that becomes like a breeding ground for more bacteria. And that's how it's a vicious and that's where the gum issues arise.

31:19 So yeah. So that's why you want to make sure the biofilm is removed adequately. Do you have any success stories of patients that you've taken care of recently where they've had? A Yeah, actually I just saw one of my patients which I had seen earlier back in 2019 before he started. And I remember it was at the time where, you know, it was before COVID, but it it was still like, I remember it being like a quite a tough time. He needed quite a lot of extractions because he, he had laryngeal carcinoma.

31:53 So he had a horrible cancer and he needed quite a bit of radiation and he had surgery, he lost his larynx. So he's got a a voice box like artificial. So he came to us and he was like, please do whatever that you need to do. So we extracted quite a lot of his teeth, but he but we kept the ones that we could. But he understood that we're doing it for the good. So he became a regular attender. So as soon as his radiation was done, he came back and he was like, so how can we fix the remaining teeth and what can I do to eat?

32:31 So we made him really nice dentures that fitted perfectly well. And we gave the smile back. We gave his function back and he comes every three to six months. As we had told him, he checks all his teeth. He's so happy. He's able to, like, live sort of normal. Life for the quality of life. Yes. So it's very important to see these and he comes with a smile and he's always so happy and I actually just saw him on Monday. So it was, it's just nice to see how we can help patients restore sort of like their function and improve the quality of life and also social adaptation because that's a very important part of cancer patients because they want to feel back to normal.

33:21 Can they get dental implants later or they can so it? Depends on, it very much depends on the kind of treatment that they have received in the past. So there are patients that we do do dental implants for, but there are some that are quite high risk. So they may not want to do it who can guide patients accordingly because not everybody can have implants, but some can. So it depends on the type of treatment that they've received. So once you get them past the acute phase, you evaluate to see if. Exactly.

33:50 So not not everyone can and not everyone cannot. So it depends on the the treatment. Are there resources available for patients or organizations that deal with these issues where patient can find it online? And also if if you want to give out your phone number for your office. Yes, I mean. You can mention it. Yes, sure. Like patients who do require dentals care, dental treatment, dental clearances. Please feel free to sorry reach out to my office which if you put my name down Leila Claggy DDS at Columbia Dental School it will pop up and you can even request appointments online.

34:37 You can register as a new patient and I, I we work with the team so we are available to help patients and you know like that's my advice that find someone who. Knows, so they can Google your name. And yes, how do you spell your last name? OK. It's that it is. So it's a KHLAGHI. OK, almost as tough as my name Cypher, So this way they'll be able to find you on the Internet. Any other tips or suggestions that you can give to patients who are undergoing radiation or chemotherapy or have cancers? Yes.

35:20 One tip I will give is that I know that you're going through a lot and it's almost impossible to imagine that what's going through your mind when you've been diagnosed with cancer. But the oral health and oral care is an important part of your life. So please take it seriously. Please find someone who can help you throughout the journey because patients often come and they complain about the oral pain more so than anything else. So we've seen it time and time again. So it's something that we can avoid and it's something that we can prevent.

36:04 Obviously we cannot prevent everything, but we can minimize the risk. So please don't take it like, I know you may think, oh, I don't want to brush my tooth now, I'm too tired. I've been through this. But please pick up a brush, brush your teeth, clean your teeth, watch what you're eating, you know, or do all the preventative measures and find a team that is able to help you and is understands what you're going through. And I think it's very, it's like a very personal thing. You know, you need to find someone who cares and knows what they're doing so that you actually can breeze through it.

36:39 And just like my patient that I mentioned, you know, he's been through a lot, but he's smiling and he's happy and you know, he's eating well, which is. It's so rewarding for us to see patients getting better. Yes, exactly. So that I want that for everybody. Sounds great. Thanks very much for coming today. I know you're very busy schedule and I. Appreciate the. Time This has been very informative and educational for people out there listening, and I'm sure they'll really appreciate. It Thank you so much.

37:10 Thank you. See you at the next Doctor Podcast show coming soon.