Thursday, February 2, 2012

Oral Cancer and Dentistry

When a patient goes to the dentist for a checkup, the last thing he wants to think about is serious illness. Many people think that worrying about decay and periodontal disease is quite enough.
Nevertheless, the mouth is a complicated place. While there are pathological processes unique to the mouth, many diseases not generally thought of as "oral" may also occur or manifest themselves in this location. One such disease is cancer. There are nearly 30,000 new cases of oral cancer each year in the United States, and eight thousand people die each year (2-3% of cancer deaths). 1-3 For all the advances of modern medicine, five-year survival has changed little in several decades.1-3
The risk factors are well known, and have been for years. Tobacco use, alcohol, and chronic sun exposure are all associated with oral cancer. Most victims are male and over 40 years old.
2-3 People who both use tobacco and drink are at much greater risk than those who have only one of these risk factors.4 It should be noted that smokeless tobacco appears to be no safer to the mouth than smoking. Smokeless tobacco has gotten increasing attention as it has become more popular.5 Chronic irritation from ill-fitting dentures and human papilloma virus have also been implicated.
Since early oral cancers are painless, they may be easily overlooked. According to James Sciubba, professor of Oral and Maxillofacial Pathology, SUNY Stony Brook, "Pre-cancers and early stage oral cancers cannot be adequately identified by visual inspection and may easily be overlooked and neglected even by highly trained professionals with broad experience."
Patients who do not receive regular dental care may never have their mouths examined for signs of cancer, and even those who have regular care may never have an adequate screening. The American Cancer Society observed as long ago as 1967 that:
"the dentist too frequently looks only at the patient's teeth; the otolaryngologist, pediatrician, and general practitioner tend to concentrate on the tonsils; the internist on the tongue; and the general surgeon on the thyroid, lateral part of the neck, and lower lip. The angle of the mandible is the “no man's land” in which all these specialties converge, none as yet having staked out a valid claim. Nor has any specialty laid claim to the extracranial head and neck as a whole."

The US Department of Health and Human Services, in its program Healthy People 2010, has a reduced mortality rate from oropharyngeal cancers as one of its objectives.10 Dentists thus must be professionally responsible for providing a comprehensive oral cancer examination for their patients.11,12 There is evidence that recent dental school graduates are more likely to screen for oral cancer risk factors and are more likely to conduct regular oral cancer examinations.13 Screening for risk factors and preventive measures, such as counseling patients regarding the use of tobacco and alcohol, may be even more important than efforts aimed at early detection.14 This counseling may be difficult for dentists who have historically felt unprepared to provide tobacco or alcohol cessation education.13
In May of this year, Surgeon General David Satcher released Oral Health in America: A Report of the Surgeon General. It is likely these services may be more easily implemented by referral to appropriate health care facilities.
15 The report found a large disparity in awareness of important oral health issues between different racial and socioeconomic groups. Minorities and the poor were found to be more poorly informed regarding oral health and its implications for general health. This had led to a "silent epidemic" of oral disease among the poor. The Surgeon General called for action to promote access to oral health care for all. Satcher's findings are borne out by the significantly higher mortality rates from oral cancer in blacks, when compared with whites.
Increased vigilance of dentists, combined with the acknowledgement of the importance of all aspects of oral care by both health care workers and patients, will go a long way toward decreasing the toll taken by this terrible, largely preventable disease.

1. Greenlee RT, Murray T, Bolden S, Wingo PA. Cancer statistics, 2000. CA Cancer J Clin 2000;50:7-33
2. Silverman S. Oral cancer. 4th ed. American Cancer Society. St. Louis: Mosby-Year Book; 1998:1-6
3. Swango PA Cancers of the oral cavity and pharynx in the United States: an epidemiologic overview. J Public Health Dent 1996;56(6):309-18
4. Mashberg A, Samit A. Early diagnosis of asymptomatic oral and oropharyngeal squamous cancers. CA Cancer J Clin 1995;45(6):328-51
5.ADA news release--Oral Lesions from Smokeless Tobacco Dissipate after Stopping Use of Tobacco Products, Study Concludes: July 1999
6. Maden C, Beckmann AM, Thomas DB, et al. Human papilloma viruses, herpes simplex viruses, and the risk of oral cancer in men. Am. J Epidemiol 1992;135(10):1093-102
7. Fouret P, Monceaux G. Teman S, Lacourreye L, St. Guily JL. Human papillomavirus in head and neck squamous cell carcinomas in nonsmokers. Arch Otolaryngol Head Neck Surg 1997;123(5):513-6
8. ADA news release--New Oral Cancer Scanner May Help Save Lives, Study Says: October 1999 |
9. American Cancer Society: The paradox of oral cancer. Brochure, 1967.
10. U.S. Department of Health and Human Services. Healthy people 2010, conference edition. Washington: U.S. Department of Health and Human Services; 2000:3-16-17
11. Horowitz AM, Goodman HS, Yellowitz JA, Nourjah PA The need for health promotion in oral cancer prevention and early detection. J Public Health Dent 1996;56(6):319-30
12. Meskin LH. Do it or lose it (editorial). JADA 1997;128:1058-60
13. Horowitz, AM, Drury, TF, Goodman, HS, Yellowitz, JA Oral Pharyngeal Cancer Prevention and Early Detection: Dentist' Opinions and Practices, JADA April 2000
source: Mark Bornfeld

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