MANILA, August 22, 2003 (STAR) By Tranquilino Elicaño, Jr., M.D. TOYM Awardee in Cancer Management  - It is indeed very timely for us to review the very important role which the dentist plays in cancer of the oral cavity which includes carcinoma of the lip, tongue, floor of the mouth, buccal mucosa and hard palate.

Since the dentist primarily deals with the mouth, he should therefore play a leading part in the detection of oral cancer. It is sad but true that a thorough examination of the mouth is rarely made routinely. The oral cavity is still no man’s land in spite of the fact that this area is examined frequently by specialists such as for example an internist who may look at the tongue to see whether it is smooth or coated or edematous. He may occasionally look at the gums and inform the patient that he has bad breath. A neurologist usually looks in the mouth to see whether the tongue on protrusion trembles or deviates. In other words, many specialists rarely look into the mouth except when examining the lesion that they are asked to deal with. These varying practitioners look for specific signs and symptoms. They seldom have an opportunity to examine a symptomless mouth. In this particular case, it is the dentist who does and so, the dental practitioner should be aware of the important role he plays in the early detection of oral cancer. In the Philippines especially, there is a high percentage of oral cancer as compared to the USA and Europe because of the high incidence of beetle nut chewing and smoking with the lighted end of the cigarette inside the mouth.

Some of the proven causes of oral cancers are the following:

Inhalation of tobacco smoke from cigarettes, pipes and cigars is a major cause. As with lung cancer, the greater the amount smoked and the higher the tar content, the higher the risk. Chewing tobacco and "snuff-dipping" carry a particularly high risk of carcinoma of the floor of the mouth where saliva pools.

Heavy alcohol consumption is a major risk factor and high alcohol mouthwashes have also been implicated. It acts synergistically with tobacco. Alcoholics also tend to have poor nutrition, and their low intake of vitamins A and C may add to their risk of developing cancer.

Carcinoma of the lip is more common in those with outdoor occupations where ultraviolet exposure is greater, and this accounts for the predominance of this tumor on the lower lip.

Physical trauma from poor dentition can lead to malignant transformation at the site of trauma, usually the lateral border of the tongue. Chronic heat trauma from claypipe smoking can lead to carcinoma of the lip.

A dentist should not forget to take a case history of his patient. A small ulcer or induration in the oral cavity often is the site of an early cancer. Because the lesion is usually painless, the patient typically is either un-aware of its existence or ignores it, considering it as a [cold sore" or as "just another something that will go away." The examiner, too often, misses such lesions simply because he is not looking for them.

The complete oral examination should include both inspection and finger palpation of extraoral areas as well as of intraoral structures. Adequate lighting, a tongue blade or depressor, a dental mirror, gauze and a rubber glove or finger cots are the only material requirements.

Dentures should be removed before starting the examination. A local anestheric spray may be required for some individuals in order to examine the base of the tongue and pharynx. Tenderness in the temporomandibular joint, color, edema or bleeding of gums, consistency of the saliva, odor of the breath, color and coating on the tongue should all be carefully noted and if abnormal, investigated further. Early Diagnosis Can Mean Cure

Alert your patients to watch for these warning signals:

1. Sore spots or ulceration of lips, tongue or other area inside the mouth that does not heal promptly.

2. White scaly area inside the mouth

3. Swelling of the lips, gums or other area inside the mouth with or without pain.

4. Repeated bleeding in the mouth with apparent cause.

5. Numbness or loss of feeling in any part of the mouth.

Discovery of fleshy looking buds of tissue; a verrucous flat leukoplastic plaque; infiltrated ulcer; scaly looking lesions; small fissure, or induration, indicate further diagnostic examination. The practitioner must determine whether to biopsy or to utilize exfoliative cytology, an adaptation of the Papanicolau smear technique.

The cytology test can be used where the lesion is of such insignificant size or presents such an inconclusive clinical picture as to make biopsy unwarranted or unjustifiable, or where the lesion is so extensive that total excision for biopsy would present a difficult problem for repair. Or, if a patient refuses a biopsy, a positive smear when shown to the patient might convince him of the necessity of a biopsy. Another instance where the oral cytology technique is useful is when the dentist refers the patients to other facilities. A cytology report indicating the site of the possible malignancy, where there are multiple lesions or widespread leukoplakia, can aid the surgeon in taking a biopsy. Oral cytology is also used advantageously for a follow-up in treated cases.

Diagnosis of oral cancer must be established on the basis of a biopsy; cytology supplements the biopsy, it never supplants it.

In order to clarify certain misunderstandings, the Author wants to emphasize that Vitamin C and Vitamin A cannot cure cancer of the oral cavity. However, over 20 years ago, the author, together with cancer experts from Canada were able to prove that the intake of high doses of Vitamiin A and Beta carotene maybe able to reverse pre-cancerous lesions such as leukoplakia.

Preliminary treatment consisting of local and dental sepsis must first be done aside from the correction of avitaminosis, if present. Treatment of the malignancy may either be surgery or radiation therapy. Surgery with the possible exception of the small cancer lesions of the lip usually needs to be extensive as for example, amputation of the tongue, or even subtotal mandibulectomy, etc. Radiation therapy however, may be the treatment of choice in a number of cases, as for example, radium implant for cancer of the anterior 2/3 of the tongue or floor of the mouth and radium mold in cases of cancer of the cheek and palate. With the advent of super voltage cobalt therapy, we may be able to successfully cure cancer of the oral cavity without wide surgical dissection. In advanced stages, chemotherapeutic agents can also be utilized for palliation.

Dentists also play an important role by extracting the teeth of oral cancer patients before they undergo radiation treatment. With the closer coordination between the various cancer specialists and the dentists, a better cure rate can be expected for patients suffering from oral cancer.

Reported by: Sol Jose Vanzi

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