Dentist probes true cause of Babe Ruth's death

Dentist probes true cause of Babe Ruth's death

By Kathy Kincade, Editor in Chief

August 18, 2008 -- Many legends surround baseball great Babe Ruth, some of mythic proportions. In addition to his amazing feats on the diamond, he was also known for his (supposedly) prodigious consumption of food, tobacco, and alcohol, which many have long believed led to his demise of throat cancer at the age of 53.

Now New York dentist William Maloney wants to set the record straight.

What is nasopharyngeal carcinoma? Nasopharyngeal carcinoma (NPC) originates in the epithelium of the nasopharynx. This aggressive form of undifferentiated squamous cell carcinoma is the leading form of cancer in certain populations in China, Southeast Asia, the Arctic, North Africa, and the Middle East. More than 50,000 people worldwide die each year from NPC (CA: A Cancer Journal for Clinicians, March/April 2005, Vol. 55:2, pp. 74-108). The most common treatment is radiotherapy; however, because the disease is often not detected until it is quite advanced, the prognosis is a less than 50% survival rate within five years. Dentists can play a key role in recognizing the signs and symptoms of NPC, according to Ines Velez, D.D.S., director of oral and maxillofacial pathology in the department of oral diagnostic sciences at Nova Southeastern University College of Dental Medicine. "The dentist may discover a lesion in the area and refer the patient to an oral and maxillofacial surgeon or to an ear-nose-throat specialist," she said. "This is a very important step, to examine the oronasopharynx." Signs and symptoms of NPC include the following: Nasal congestion/obstruction Feeling of fullness in the throat and sinus regions Middle-ear inflammation and pain Headache Neck and facial pain Decrease in hearing in one ear Cervical lymphadenopathy Eye pain and swelling

After a year of extensive research into Ruth's personal and medical histories, Dr. Maloney says that, contrary to the history books, Ruth did not die of throat cancer. Rather, he succumbed to nasopharyngeal carcinoma (NPC), a rare genetic cancer that is often misdiagnosed (see sidebar).

Dr. Maloney, a general dentist and assistant professor at the New York University College of Dentistry, is not the first to discover this little-known fact; in 1999, a group of doctors from the University of California, San Francisco published an article in the medical journal Laryngoscope (January 1999, Vol. 109:1, pp. 1-2) claiming that, based on reviews of Ruth's autopsies, he did not die of larynx cancer but of NPC. In particular, the autopsy clearly showed that Ruth's larynx was cancer-free.

But Dr. Maloney's research, published in the Journal of the American Dental Association (July 2008, Vol. 139:7, pp. 926-932), takes a more in-depth look at those earlier findings, putting them in the context of Ruth's diagnostic and treatment experiences and his eventual role in early cancer research.

"I set out to write a paper on the negatives of smoking and drinking as a cause of oral cancer, using Ruth as an example," he said. "Early on I was dismayed to find out that he didn't have oral cancer but NPC."

According to Dr. Maloney, during the summer of 1946, Ruth experienced intense left retro-orbital pain and was admitted to a hospital in September. The entire left side of his face was swollen and his left eye completely shut. The doctors misdiagnosed him initially with infected teeth and recommended he have several teeth extracted, which he did. They also thought he might have sinusitis and treated him with antibiotics. When these efforts yielded only minimal relief, Ruth subsequently underwent radiation therapy after the doctors assumed that, because of his history of heavy alcohol and tobacco consumption, he had laryngeal carcinoma.

Such misdiagnoses are common with NPC even today, Dr. Maloney said.

"This disease is very hard to diagnose," he said. "It is occurs in the back of the throat, on top of the pharynx, usually originating in the lateral wall of the nasopharynx. NPC doesn't really have any oral symptoms; the main symptoms are problems with one eye, loss of hearing in one ear, and nose bleeds. But, usually, when it gets to that stage, it's pretty far along."

Dr. Maloney believes that dentists can play an important role in diagnosing NPC and helping patients with NPC to better manage the effects of radiotherapy, the most common treatment for NPC.

"If a patient comes in complaining about ear problems or eye problems on one side or nose bleeds, they might think it has something to do with their teeth," he said. "But, if on examination, there isn't anything wrong in the oral cavity, they should be referred out to an ENT surgeon. If this disease is caught early enough, there is a very high success rate."

Unfortunately for Ruth, the misdiagnosis allowed the disease to continue to advance. He ultimately turned to an experimental treatment that was the precursor to what we now know as chemotherapy. Working with a New York oncologist, Richard Lewisohn, in 1947 he began daily injections of teropterin -- Ruth was the first human subject ever to undergo such treatment. According to a 1998 story in the New York Times, the treatment brought him some much-welcome relief and prolonged his life for a year, Dr. Maloney said.

It also gave him the opportunity to help others. ''I realized that if anything was learned about that type of treatment, whether good or bad, it would be of use in the future to the medical profession and maybe to a lot of people with my same trouble,'' he wrote in his autobiography (The Babe Ruth Story, E. P. Dutton & Co., 1948).

"I was struck by the fact that this great superstar was so willing to help future generations," Dr. Maloney said. "He has been so documented throughout history as a great ballplayer and celebrity, but this part of his life, which is so historically and medically significant, hasn't been documented well at all."

Remote receptionists? Outsourcing hits the front office

Remote receptionists? Outsourcing hits the front office

By Laird Harrison, Senior Editor

August 15, 2008 -- When patients call the office of Kalpana Madhavan, D.M.D., in Rockville, MD, they might end up talking to a receptionist in Idaho. Or Montana. Or any of six other states. It all depends on who is handling her account that day.

Dr. Madhavan is one of the first customers in a new service, offered by Planet DDS of Irvine, CA, that matches receptionists working from home with dentists working from their offices. "It keeps me productive," Dr. Madhavan said. "I think it's taking dentistry to a level that we never imagined."

“It keeps me productive. I think it's taking dentistry to a level that we never imagined.”
— Kalpana Madhavan, D.M.D.

Dentists have long contracted with bill collecting services; some have used after-hours medical answering services; and multioffice practices have tried centralizing office management. But the notion of an individual dentist contracting with a remote receptionist to make and confirm appointments and pursue insurance claims is relatively new, said Irvin Lubis, D.M.D., a former periodontist in Boonton, NJ, who now works as a practice management consultant for dentists.

The possibilities are growing with new Web-based practice management software that allows people in disparate locations to enter information into the same appointment book and access the same charts and insurance records.

Other companies offer such services, including Call Desk of Portland, OR, which also has U.S.-based receptionists. But Planet DDS claims to be the only one specializing in dental practices. The business is not based on medical answering services but on the airline Jet Blue, whose customer service representatives work from home, said William Jackson, D.D.S., vice president of Planet DDS.

The Planet DDS price structure is also unusual. The company charges $1.25 per inbound call and $1.50 per outbound call, with volume discounts. (Call Desk charges $150 a month for phone services.) For collections, Planet DDS takes a cut of 2% to 3%. Dr. Jackson claims this is about half of the going rate. The company can charge less because of the efficiencies afforded by the Web-based practice management software, he said.

The software can be used without the virtual receptionists, but if you want the virtual receptionists, you have to use the software. It costs $150 per month for a small office and $250 per month for a large one. (While that's more expensive than buying software to run on your own computer, Dr. Jackson said, it offers other advantages: it's accessible from anywhere with an Internet connection, and it automatically backs up your data.)

How it works

New patients who call Dr. Madhavan's office will get a Planet DDS receptionist who can schedule an appointment for them and take down their insurance information, as well as guide them to a Web site where they have the option of entering their medical history. "By the time the patient walks in, they have already verified the insurance," Dr. Madhavan said. After the appointment, a virtual receptionist processes the billing, allowing Dr. Madhavan and her two assistants to focus on dentistry.

The service is not for everyone, Dr. Lubis said. He is leery of trusting someone who works far away to handle the minute-by-minute demands of running an office. "The person at the desk is the quarterback," he said. "In an emergency, she moves people up, she moves people down. She has to have her finger on the pulse of it."

And David Landau, D.D.S., a cosmetic dentist in San Diego, said he wouldn't be interested because his busy practice relies on delivering a "value-added" experience for all patients, and communication is critical to ensuring this happens.

"I think it is an idea that could work in many practices, but I am skeptical if it would fit mine," he said. "My practice consists of two doctors, three hygienists, and eight or nine other team members. In many ways, it would be great to have fewer people to manage, but I would worry about the continuity of communication. Our business model is high-quality dental care supported by a high-service, 'value-added' experience."

But Dr. Madhavan, who recently opened her practice, said the service fits the needs of a small office. The answering service allows her assistants to spend most of their time chairside. But both are trained to work in the front office, so if someone walks in the front door, they can respond to the chime with a friendly smile. A second phone line rings into the office so Dr. Madhavan's suppliers can reach her directly.

Dr. Madhavan likes having fewer employees on her payroll. She also likes paying per phone call so she is not charged for services she isn't using; she once hired a receptionist who spent a lot of her time in the office planning bridal and baby showers. When the receptionist went on vacation, Dr. Madhavan found herself puzzling over which new patients had insurance. Now that never happens, and the service has eliminated a lot of headaches, she said.

So far, every time Planet DDS has offered a new service, she has bought it. "Right now the service is only 9 to 5," Dr. Madhavan said. "I would like it to be 24/7 because I have a new practice and I want to capture every patient who calls."

This would probably mean hiring receptionists outside of the U.S. Dr. Jackson said his company has had conversations with people in India and the Philippines, but mostly about dealing with insurance companies. Many of his clients don't want prospective patients to hear an Indian or Filipino accent on the other end of the line, he said.

Dr. Madhavan, who grew up in India, isn't bothered by the accent. But she's still not sure she would want a virtual receptionist there.

Her concern? U.S. insurance policies might be incomprehensible to anyone who didn't grow up with them.

Portable dental kit mistaken for bomb

Portable dental kit mistaken for bomb

By DrBicuspid Staff

August 15, 2008 -- A hazmat team and a bomb squad were called to the Cincinnati/Northern Kentucky International Airport on the evening of August 13 after luggage workers spotted a suspicious package that turned out to be a portal dental examination kit.

Workers saw white powder and wires coming from a bag in the cargo area of a plane, according to the Associated Press. After calling the phone number on the luggage tag, airline personnel were able to determine that the bag belonged to a dentist from Ecuador and that the bag had wound up in Cincinnati by mistake.

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