Tag Archives: oral health

Oral Cancer: To Screen or Not to Screen?

April is Oral Cancer Awareness Month, and this year, it’s involved some controversy.

It began with the release of a Consumer Reports article that included oral cancer screening among 8 “to avoid.”

“Most people,” they wrote, “don’t need the test unless they are at high risk, because the cancer is relatively uncommon.”

Not long after, a government task force said “that there is not enough published evidence to recommend for or against screening for oral cancer by primary care professionals.” Though dentists aren’t considered “primary care professionals” in this case, it’s an easy detail to miss.

So is CR right about when they say such testing isn’t necessary?

While it’s true that oral cancer used to be rather rare, with mostly smokers and heavy drinkers being at risk, that’s no longer the case. As we’ve noted before, rates have been skyrocketing, largely due to the human papillomavirus, or HPV. More than 35,000 new cases are diagnosed each year, and the 5 year survival rate is only 50%. Part of the reason for that last statistic is that many oral cancers are detected quite late – which is why dentists have been speaking up more and more about the benefits of early detection.

Unlike many other kinds of cancer screening, a screen for oral cancer is hardly invasive. At minimum, it involves a visual exam that can quickly and easily be done as part of a routine dental exam.

oral_cancer_check

Many also use technology to aid to visual screening. In our office, we have a device called VelScope, which uses a blue excitation light to make healthy areas appear fluorescent and problem areas, dark. This isn’t some extra procedure; once a year, it’s a part of every adult patient’s exam.

Brian Hill, executive director of the Oral Cancer Foundation, nicely sums up the case for screening:

It isn’t an invasive exam, there’s no radiation (no long-term exposure issue), it is painless, it’s usually free, and you’re already sitting in the dentist chair. Why would you not get it?

Indeed.

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HPV, Oral Cancer & Gum Disease

According to the CDC, more than 36,500 new cases of mouth and throat cancer are diagnosed every year. The 5 year survival rate is only about 50%.

But that rate is a whole lot better in cases where the cancer is detected early. That’s why, in my office, oral cancer screening – using VelScope – is included in every adult patient’s exam at least once a year.

A recent paper underscores why this matters.

Published last month in Head & Neck Oncology, the study confirms that

oral sex with multiple partners is one of the significant risk factors for oral cancer and oropharyngeal cancer. Young people, who increasingly practice oral sex especially with many partners, may be driving the increase in these cancers.

The culprit, as we’ve discussed before, is HPV (human papillomavirus). More known for causing cervical cancer, HPV is also a major cause of oral cancer. In fact, it’s surpassed tobacco as the leading risk factor: While smoking rates have plummetted, oral cancer rates have soared. And that risk increases along with sexual activity. According to the current research,

HPV infection is likely to be sexually acquired with increased risk of oropharyngeal cancer with either many (more than 26) lifetime vaginal-sex partners or six or more lifetime oral-sex partners.

Why is the mouth so vulnerable to HPV transmission?

It must be remembered that the oral cavity is a battlefield of healing mucosal micro abrasions which could in the right circumstances of altered local host defenses allow viral inculcation, infection and entrenchment leading to somatic genetic change. Changes in immuno-tolerance at these “special” immuno-modulating sites…combined with further environmental triggers then lead to cancerous changes. Basically, viral “genes load the gun and environment pulls the trigger.”

So maybe it’s no surprise that earlier research has suggested a connection between gum disease and oral cancer. The initial study found that precancerous lesions were twice as prevalent – and tumors, four times as prevalent – in those with periodontal disease than those with healthy gums. Inflammation appears to be the key factor, as lead author Dr. Mine Tezal recently discussed in an interview with Dr. Bicuspid about her ongoing research:

The results of our recent study suggested an association between chronic local inflammation and tumor HPV status of head and neck cancers. HPV infects only basal cells of the epithelium and gains access through breaks in the mucosa….

In this inflammatory environment, HPV is also shed in greater amounts leading to increased risk of viral transmission. If prospective studies in cancer-free populations confirm that chronic inflammation is a significant factor in the natural history of oral HPV infection, the public health implications would be important.

Thus, another cancer-preventive measure, she suggests, is to control inflammation in the mouth. And she likewise confirms what the Head & Neck Oconology paper showed: frequency of exposure to the virus matters. A lot.

HPV is a commonly transmitted virus and the majority of the infections are cleared rapidly by the immune system without causing disease. Rather than the mere presence of the virus at one time point, its persistence is critical for the development of HPV-related diseases. [emphasis added]

Learn more steps you can take to lower your risk of oral cancer from my earlier post “The Oral Cancer Pandemic & How You Can Keep Yourself Safe.”

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Why Does Poor Oral Health Remain Such a Problem?

Every so often, a new story comes out about the American struggle with oral health. Not long ago, for instance, we heard about how 20% of Americans have untreated decay and most have some history of cavity repair: 40% of children, 52% of teens and 75% of adults. Other studies say that by the age of 65, as many as 90% of adult Americans have experienced decay in their permanent teeth.

Why is it such an ongoing problem?

For one, there’s the standard American diet, which is chock full of sugars even before factoring in the sodas, juices and other sweet beverages we’ve come to drink more of. These, along with refined grains and other processed carbs, feed the pathogenic (disease-causing) microbes involved in oral disease. Sugar has other negative health effects, too, and makes us more susceptible to illnesses of all kinds.

Add to this lifestyle factors such as limited physical activity, high stress, poor and insufficient sleep, high drug use (including prescription drugs, alcohol and tobacco) and the like: all these factors similarly weaken the body’s innate self-regulating abilities. We become prone to illness – or at least suboptimal health.

Then there’s the matter of lack of knowledge about dental health and hygiene – a point made quite vividly by survey findings released by the American Dental Association last week. The headline on their press release?

Americans Score a D
on National Oral Health Quiz

The “quiz” was a series of true/false questions answered by nearly 1500 adults. Here’s what the ADA found – and the correct answers:

  • 90% think you should brush after every meal.
    Twice a day is the usual recommendation. And as mentioned, you should usually wait about a half hour after eating or drinking anything before you brush.
  • 65% think you should replace your toothbrush twice a year.
    Every three months is more like it.
  • 75% don’t know when a child should have his or her first dental visit.
    It should happen as soon as their first tooth erupts or no later than their first birthday.
  • 81% think sugar causes cavities.
    Only part true. As mentioned above, sugars feed pathogenic microbes in the mouth, but it’s the acidic waste they produce that actually damages the teeth.
  • 59% don’t know that those microbes can be passed from person to person.
    Like other infectious agents, oral bacteria can be passed along from one person to another – through things like kissing or sharing utensils.

Taking good care of your health – dental and systemic alike – means understanding how your body works. That’s why you may find your dentist or hygienist always explaining and teaching at your appointments – teaching that, unfortunately, some patients tune out for various reasons. But the teaching does matter, so we keep doing it. It’s central to our work. As I wrote before,

I can’t speak for all dentists, of course, but as a dentist, it’s important to me that you understand what we’re doing and why we’re doing it, as well as what you can do to gain and sustain more optimal oral health in general. After all, dentists are doctors, too – physicians whose specialty involves the teeth and oral cavity. You know how the word “doctor” came about? The English word comes from the Latin word docere, which means “to show, teach or cause to know.”

Teaching is part of our job.

Image by Jacob Barss-Bailey, via Flickr

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Raspberries, Piercings & Smoking – Oh, My!

So back to blogging, following up on a few older posts with more recent items I ran across during the hiatus…

Nontoxic Oral Cancer Treatments

We’ve looked at causes and early detection of oral cancer, but then what? Well, if a pair of recent studies holds up, we just might wind up treating precancerous lesions with raspberries.

“Part of the biggest clinical challenge,” says Dr. Susan Mallery in DrBicuspid’s report on her work, “is that we cannot currently identify which lesions will progress to oral cancer. Having nontoxic and effective treatment options available would be a great benefit to both patients and healthcare practitioners.”

In a 2010 study in Pharmaceutical Research, Dr. Mallery’s team found that applying a black raspberry gel directly to the lesions kept precancerous cells from becoming cancerous.

Based on the known mechanisms by which berry compounds function at the cellular levels, researchers speculate that the promising gel trial results reflect activation of two related pathways – apoptosis and terminal differentiation – in the premalignant cells. The ultimate benefit is that damaged cells don’t continue to divide and are therefore not retained.

A new study by the team, published in Molecular Pharmaceutics, showed similar efficacy of patch-delivered fenretinide, a synthetic vitamin A compound. The authors suggest that these “chemopreventives” could be used alone or in rotation, though the raspberry gel was enough for many.

“We’re getting a pretty good handle on what enzymes you need and how you metabolize the compounds, which will give a predictive indicator if you’re going to be a good responder to the raspberry gel alone,” Dr. Mallery said.

How Body Piercing Can Go Wrong

A while back, we looked at a few of the problems oral piercings can cause for your teeth and gums – from infection to pushing teeth out of alignment. But there are others.

Last month, the American Journal of Clinical Dermatology published a comprehensive review of “the medical consequences of body piercing.” First, there are those that can crop up regardless of where the piercing is.

Localized infections are common. Systemic infections such as viral hepatitis and toxic shock syndrome and distant infections such as endocarditis and brain abscesses have been reported. Other general complications include allergic contact dermatitis (e.g. from nickel or latex), bleeding, scarring and keloid formation, nerve damage, and interference with medical procedures such as intubation and blood/organ donation.

Then there are “site-specific” problems. Of concern to dentists:

Oral piercings may lead to difficulty speaking and eating, excessive salivation, and dental problems. Oral and nasal piercings may be aspirated or become embedded, requiring surgical removal.

What the report doesn’t go into, though, are concerns of biological, holistic or integrative practitioners over punching through acupuncture points and housing metal in the body. These can block and disturb energy along the meridians, which can damage health over time. You can learn more about the issue in this helpful overview.

Smokers Avoid the Dentist

Not long after we looked at why smokers need to kick their habit before getting treatment for gum disease – a disease that affects tobacco-users disproportionately – the CDC released some new and sad data on smokers, dental problems and dental care.

The CDC looked at 2008 survey responses from more than 16,000 adults ages 18 through 64.

More than a third of smokers reported having three or more dental problems, ranging from stained teeth to jaw pain, toothaches or infected gums. That was more than twice as much as people who never smoked.

But 20 percent of the smokers said they had not been to a dentist in at least five years. Only 10 percent of non-smokers and former smokers had stayed away that long, the study found.

Smokers seem to be aware their dental health is worse “but they’re not doing anything about it,” said Robin Cohen, a CDC statistician who co-authored the new report.

Why not?

Half said they couldn’t afford it, which makes sense: Smoking rates are higher among lower income groups, it’s an expensive habit and the amount and type of damage it causes can quickly inflate a dental bill. I suspect fear plays a role, too – fear of The Lecture, as noted before, and fear of finding out just how bad the problems are.

Unfortunately, the avoidance tactic usually ends up costing much more. According to a study in the Journal of Periodontology, patients with gum disease who did without periodontal treatment could only replace 4 teeth before they were spending more than they would have for a lifetime of periodontal care.

A lifetime!

“Feasible”?

Last, a headline – from a story about recent UK debates on the use of mercury amalgam in dentistry:

Well, amalgam fillings are sure as heck not feasible in any term!

Images by Lottery Monkey, jpmatth and Savannah Roberts, via Flickr

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4 Things You Might Not Know About Kids’ Oral Health

 

Some interesting facts as we wind down National Children’s Dental Health Month:

  1. Oral health affects how kids do in school.
    According to research published in the American Journal of Public Health, children with poor oral health are three times more likely to miss school because of dental pain and do tend worse academically. Missing class isn’t the issue. Kids who skip school to get routine preventive care show no drop in academic performance.
  2. Bacteria that cause tooth decay can colonize before the teeth come in.
    Earlier this year, scientists using DNA sequencing identified hundreds of bacterial species in the saliva of infants. These included S. mutans, which plays a very big role in the development of early childhood caries (EEC). Such findings underscore the need to begin oral hygiene early and take your child for their first dental visit shortly after their first tooth erupts or around their first birthday.
  3. Teething gels that contain benzocaine can be a problem.
    Benzocaine is a pain-killer commonly found in products such as Orajel, and the FDA recommends against it for teething infants. Why? Such gels raise the risk of methemoglobinemia, or “blue baby syndrome” – a blood disorder that keeps oxygen from getting to the body’s cells. Let your child use teething rings instead, or gently massage their gums with your finger.
  4. Secondhand smoke can damage children’s teeth and gums.
    Studies have found that children regularly exposed to secondhand smoke have more cavities, worse periodontal health and factors that exacerbate both problems: reduced salivary flow, more acidic saliva and higher levels of pathogenic bacteria.

Image by CarbonNYC, via Flickr

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Gum Disease? Smoker? Why You Need to Kick the Habit Before Getting Treatment

According to a recent poll, 1 in 10 smokers try to hide the fact from their physician. Most say they do this to avoid getting get lectured about their habit. And that’s understandable. After all, most smokers know they should quit. Many have tried. But the pleasures, rituals and effects (physical and mental) – and so, the addiction – often win out.

Since so much of tobacco’s damage isn’t readily visible in a routine medical visit, hiding the habit may be fairly easy – especially if you’re a light smoker, as the poll says many hiders are. Hiding it from a dentist, though, is tougher. Yes, you can mask bad breath for a while. Yes, you can diligently whiten your teeth. But you can’t mask things like bleeding gums, bone and tooth loss or cancerous lesions.

While most Americans have some degree of gum disease, the problem, as noted before, is much worse among smokers. According to research published in the Journal of Periodontology, over half of all cases may be due to smoking, and smokers are four times more likely to develop it. Why? Among other reasons, they “may be more than 10 times more likely than nonsmokers to harbor the bacteria that cause periodontal disease and are also more likely to have advanced periodontal disease.”

And no, it’s not just about cigarettes. You don’t get a free pass just because you smoke cigars or a pipe. The effect is similar. And the more you smoke, the greater the risk. Chewing tobacco carries its own oral health risks.

While gum disease can lead to bone and tooth loss, it’s not a necessary cause. Smoking alone is enough of a trigger, and its effects persist even after decades of living smoke-free. While we can try to spur new bone growth or at least slow the rate of loss, there’s currently no sure-fire fix.

Because of tobacco’s pernicious effects on both the hard and soft oral tissues, an increasing number of periodontists refuse to treat smokers until they kick the habit. Smokers may be surprised, frustrated, hurt or even offended by this. Obviously, they care enough about their oral health to consult with a specialist. But that care needs to motivate a successful quit, as well. After all, would you start repairing a flooded home while water was still gushing in? Or a fire-damaged home while flames are still raging?

For while periodontal treatment may help in the short term, long-term prognosis for smokers is poor. This is borne out both clinically and through research.

Among the latest research is a study just published in the American Journal of Medical Sciences. For it, the authors reviewed over 40 years of research on the impact of smoking on perio surgery outcomes. Of the two dozen studies that met their criteria, 2/3

showed that reductions in probing depth and gains in clinical attachment levels were compromised in smokers in comparison with nonsmokers. Three studies showed residual recession after periodontal surgical interventions to be significantly higher in smokers compared with nonsmokers. Three case reports showed periodontal healing to be uneventful in smokers.

But this can be new incentive to quit. No one wants to waste money on treatments not likely to help much or last long. So the choice becomes one of continued tobacco use and worsening oral health or quitting and getting help to regain periodontal health and keep as many natural teeth as long as possible. (After all, replacing teeth isn’t cheap either: a single implant can cost several thousand dollars!) For the good news is that although the risk of tooth loss persists, the effects of smoking on gum tissue are reversible. You can undo a lot of damage.

You just have to quit the cigs first.

Some natural, drug-free tips for quitting smoking

Abstracts on the tobacco-perio health link

 

Image by Marko Miloševic, via Flickr

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The Need to Talk About Oral Cancer

The British Dental Health Foundation recently distributed some interesting UK survey results on oral cancer. Reading their media release, I wondered: Would US survey results be similar?

What they found:

  • 88% of the public would like to be checked for oral cancer at their dental appointments.
  • 89% of dentists check for signs of oral cancer.
  • 68% use tools like VELscope to check for cancer.

More, every dentist surveyed – 100%! – said that they consider it their role to promote oral cancer awareness. And yet the BDHF found that

  • 84% of dentists do not explain the risks and symptoms of mouth cancer to their patients.
  • Almost half – 43% – do not provide oral cancer educational material to patients.

How do you effectively “promote awareness” then?

Earlier this year, I wrote about the sharp increase in oral cancer rates:

Once upon a time, oral cancer was a disease limited largely to tobacco users and heavy drinkers. For all others, the risks were thought to be very low, and the rate of disease remained fairly steady.

And then it started going up. And fast.

How fast?

Between 1974 and 2007, cases of white men with oral cancer shot up by 225%.

At the same time, there was a five fold increase in young adults with oral cancer.

Incidence has especially skyrocketed for women. In 1950, for every 6 men who developed oral cancer, only one woman did. Today, that ratio has narrowed to 2 : 1.

Clearly, oral cancer is something we need to be talking about, dentists and patients alike. So it’s no surprise that the BDHF’s media release about this survey focused so sharply on the need for better communication.

Chief Executive of the Foundation, Dr Nigel Carter…said: “Good communication in healthcare is vital for both the professional and the patient. In dentistry it allows the dentist to explain certain procedures, which can often be very technically-minded. The patient can then come back with any further questions they may have about the treatment, what is involved and what may happen afterwards. If either of these roles is ineffective then it can lead to a failure of communication.”

“Mouth cancer cases are increasing at a phenomenal rate due to choices in lifestyle such as smoking and alcohol. The disease, its symptoms and risk factors need to be discussed honestly and openly more often and there’s no better place to start than at a dental check-up.

“Knowing the risks and learning how to self-examine are key when it comes to the early detection of mouth cancer, where it can dramatically improve survival rates to 90 per cent. Without early detection, half will die – it really is a silent killer.”

If you’re not sure your dentist checks for cancer at your regular appointments, just ask. Ask your dentist to explain the procedures and what he or she looking for. Talk with him or her about any risk factors you may have and preventive steps you can take.

I can’t speak for all dentists, of course, but as a dentist, it’s important to me that you understand what we’re doing and why we’re doing it, as well as what you can do to gain and sustain more optimal oral health in general. After all, dentists are doctors, too – physicians whose specialty involves the teeth and oral cavity. You know how the word “doctor” came about? The English word comes from the Latin word docere, which means “to show, teach or cause to know.”

Teaching is part of our job.

To learn more about key risks and symptoms of oral cancer – as well as why we’re seeing so much more of it these days – see my earlier post, “The Oral Cancer Pandemic & How You Can Keep Yourself Safe.”

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