Prevention of Oral cancer and Traumatic dental injuries.pdf

Prevention of Oral cancer and Traumatic
dental injuries (TDIs)

Introduction
 Oral squamous cell carcinoma (OSCC) accounts for > 90% of oral cancers.1,2
 Term = oral cancer (used
 National Cancer Registry (NCR) in SA established in 1986
 Data published by NCR used in development of national guidelines for prevention &
cancer research
1, Franceschi, S., et al. "Comparison of cancers of the oral cavity and pharynx worldwide: etiological clues." Oral oncology 36.1 (2000): 106-115.
2.Moore, S. R., et al. "The epidemiology of mouth cancer: a review of global incidence." Oral diseases 6.2 (2000): 65-74.

Oral cancer prevention
 One of the severe/fatal dental conditions – dental professionals may encounter
 Dental professionals must understand
 Epidemiology
 Natural history
 Options for prevention
 Screening
 Treatment
 No evidence on the effectiveness of screening
 Progress has been made on treatment but this has not improved survival rates
 Preventive strategies by the dental professions alone are unlikely to be successful
 = Co-ordinated Comprehensive Public Health Strategy is advocated

Epidemiology of oral cancer
 OC is the sixth most common cancer worldwide & more common in developing than
developed countries.3-4
 OC generally refers to cancers of the oral cavity and the oropharynx
 Worldwide, cancers of the oral cavity and oropharynx:
= 220 000 new cases per year in men (5% of all cancers)
= 90 000 in women (2% of all cancers).
 Despite it causing more deaths than other diseases & disorders, has not received
adequate attention from either medical & dental profession
 Focus is more von dental caries & periodontal infections. 5
 Regardless of the easy access of oral cavity for clinical examination, OSCC is usually
diagnosed in advanced stages.
3, Shah, Jatin P., and Ziv Gil. "Current concepts in management of oral cancer–surgery." Oral oncology 45.4-5 (2009): 394-401
4, Warnakulasuriya, S. (2009).
5, Rheeder P,et al 2012

Epidemiology of oral cancer
 In the last 30 years, the 5-year survival rate of patients with oral SCC has not
improved despite advances in di-agnostic techniques and improvements in treatment
modalities
 The incidence and prevalence of oral SCC are increasing, particularly in younger
persons. 6-7
Age & Gender
 Affects more men than female (M:F= 1,5:1). (Reason could be more men indulge in
high – risk habits)
 Probability with period of exposure to risk factors
 Peak incidence with age is in sixth and seventh decades ( Median age US 62yrs).8
 However, the incidence of oral SCC in persons under the age of 45 is increasing.4
6, Neville & Day, 2002
7,Rapidis et al 2009
8, Institute NC, 2010

Epidemiology of oral cancer cont…
 In SA males: more coloured males than white & black males
 Except Asian women where it is 6 x more
 INDIA:
 40% of all Cancer in India
 UK:
- 1-2% of all Cancer in UK
 SA (2001) :
- 4.7% of all Cancer in males; 1.8% of all Cancer in females
 Cancers in SA (2002)
 tobacco and alcohol consumption suspected risk factors
 oral cavity (87 men and 37 women),

Epidemiology of oral cancer cont…
 An important risk factor for OSSC in the mouth, but more so the oro-pharyngeal
region, is unsafe sexual practices. (OA ayo-Yusuf et al, 2013)
 This may be particularly relevant in South Africa, given the high incidence of HI/AIDS
(Department of Health, 2009)
 And the fact that HIV infection may increase the risk of acquiring infections with new
human papillomaviruses (HPV) and decrease the rate of HPV clearance in both
women and men (Mbulawa et al, 2012)

Figure. 3 Comparison of the most common cancers in more and less developed countries
in 2000. WHO
0 100 200 300 400 500
Lung
Stomach
Prostate
Colorectal
Liver
Oesophagus
Bladder
Oral cavity
Non-Hodgkin Lymphoma
Leukaemia
Larynx
Kidney
Pancreas
Other pharynx
Brain, etc.
More developed
Less developed

Persons Males Females
Rank
Cause of death Deaths Rank Cause of death Deaths Rank Cause of death Deaths
1
Trachea/bronchi/
lung cancer
6885 1 Trachea/bronchi/
lung cancer
4669 1 Cervix cancer 3498
2
Oesophageal cancer 5579 2 Oesophageal cancer 3566 2 Breast cancer 3156
3
Cervix cancer 3498 3 Prostate cancer 2524 3 Trachea/bronchi/
lung cancer
2216
4
Breast cancer 3206 4 Liver cancer 1666 4 Oesophageal cancer 2013
5
Liver cancer 2651 5 Stomach cancer 1386 5 Colo-rectal cancer 1410
6
Colo-rectal cancer 2567 6 Colo-rectal cancer 1157 6 Liver cancer 986
7
Prostate cancer 2524 7 Mouth and oropharynx
cancer
985 (4.6%) 7 Stomach cancer 962
8
Stomach cancer 2348 8 Leukaemia 818 8 Pancreas cancer 752
9
Pancreas cancer 1541 9 Pancreas cancer 789 9 Ovary cancer 707
10
Leukaemia 1465 10 Larynx cancer 633 10 Leukaemia 647
11
Mouth and
oropharynx cancer
1386 (3.3%) 11 Lymphoma 601 11 Corpus uteri cancer 638
12
Lymphoma 1032 12 Bladder cancer 469 12 Lymphoma 431
13
Larynx cancer 746 13 Bone and connective
tissue cancer
360 13 Mouth and oropharynx cancer 401
(2.0%)
Numbers of cancer deaths by cause, South Africa 2000 – Revised (MRC)

Total number of US Oral Cancer cases and percent of population, by selected
characteristics, 2004
Gender All Ages 0 to 9 10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 plus
Total Number
Male 157,250 23 492 1318 3276 14,407 37,003 40,095 60,638
Female 87,223 101 501 1668 3489 8222 15,686 18,110 39,446
Percent of
Total
Population
Male 0.0732
not enough
data
0.0018 0.0050 0.0144 0.0548 0.1667 0.2775 0.6367
Female 0.0372 0.0004 0.0022 0.0066 0.0142 0.0289 0.0607 0.1009 0.2926

Aetiology
• Oral cancer aetiology is largely understood and it is preventable (appropriate
measures are undertaken)
• Risk factors
1. Smoking tobacco & Chewing tobacco & betel quid
2. Heavy consumption of alcohol
3. Presence of potentially malignant lesions
• Predisposing factors
1. Trauma;
2. Viral infections;
3. Genetic disposition;
4. Dietary deficiencies (vit A,C,E & Fe);
5. Sunlight

1. Tobacco use in SA
• 21% or 6.5 million smokers in SA (33% M > 10%F).
• 1.5 million smokeless tobacco users (black women 11%, >
men 1%).
• Smokeless tobacco (ST) or Snuff use, more common amongst
SA black women than men
– Its traditional & is most commonly used for perceived
medicinal properties and in cultural ceremonies.

2. Alcohol use
Men Women
No more than 21 units / week= 210ml (± 1 glass)
No more than 4 /day= 40ml ≈ 4 tbs)
No more than 14 units/ week = 140ml (± ½ glass)
No more than 3/day≈. 3 tbs
One unit of alcohol is 10 ml by volume, or 8g by weight, of pure alcohol
• Heavy drinking ≈ >2 drinks/ day for men OR >1 drink /day for women.
• Alcohol use and the associated burden in SA
The MRC per capita consumption of alcohol in SA is between 10.3 and 12.4 litres per head, incl. homebrewed alcohol (Rehm
et al., 2004).
• WHO (2002)  45% of men and 70% of women in Afro Region E ( SA included) abstain from drinking alcohol.
• Per cap. consumption amongst drinkers in SA is higher than the regional average (Parry, 2005). Same as UK (7.8 l) and the
Ukraine.
Tobacco use and excessive alcohol consumption have been estimated to account for about 90% of cancers in the oral cavity.

3. Presence of potentially malignant lesions
• Leukoplakia & erythroplakia 2-6% may change to malignancy
4. Dietary issues
• Diet low in Vit A, C, E + Fe  reduction in the protective function of the oral
mucosal barrier & thus reduce resistance to harm by physical onslaughts
• Antioxidants in fresh fruit =protective

Challenges about Oral CA
• Even though tech & Rx have improved, QoL of affected
people have not improved
• Survival rate improves with early detection
• Survival rates differ significantly with :-
A. Type/location of 10 site {more further located, poorer prognosis}
B. Different socio-economic groups {the poorer have a poor prognosis ‘cos of
presenting late @ facilities; people in unskilled manual jobs tend to smoke & drink alcohol more}

Prevention
• Aim of cancer prevention is to reduce the incidence of the disease;
• Cancer control to detect the disease in its initial stages and to promptly institute
effective and efficient treatment
• Measures directed at the public to reduce the incidence of oral SCC and to alert
those at risk to the benefits of early detections:
- Education about early signs & symptoms
- Hazards of delaying seeking professional advise
• Professional measures should include:
- Making available of immediate effective & efficient medical treatment
- Screening programme for high- risk population
• Dental prof: tend to focus on the indiv. level especially cancer screening
A broader public health strategy is NB

Screening
To screen or
not?? Based on
• Benefits,
• Costs,
• Effectiveness,
• Feasibility, appropriateness?
There is insufficient evidence that screening should be
recommended
Disease No disease
Test Positive TP FP
Test negative FN TN

Clinical approach
A. Comprehensive medical history
– Detailed history for all new patients and recall patients
– History of tobacco use AND alcohol use
– Record and refer back on feedback/recall visits
B. Thorough oral examination
– Opportunistic screening can be done even though national screening cannot be recommended
– Extra & intra-oral hard & soft tissue exam == prompt referral
– Greater risk: > 45, smoking, alcohol heavy use, snuff users, leuko/erythroplakia present
C. Patient counselling:
I. Quit smoking- smoking cessation
II. Minimal alcohol use
III. Eat five portions of fruit a day [availability; affordability]
– Drug use is addictive
– The level of drug use in society depends upon:
• Affordability
• Availability
• Social acceptability
„It is very easy to
quit, I‘ve done it a
thousand times!“
Mark Twain

The "5 A's" Model for Treating Tobacco Use and
Dependence – 2008 in Smoking cessation protocol
1. Ask about tobacco use. Identify and document tobacco use status for every patient at every visit.
2. Advise to quit. In a clear, strong and personalized manner urge every tobacco user to quit.
3. Assess willingness to make a quit attempt. Is the tobacco user willing to make a quit attempt at
this time?
4. Assist in quit attempt. For the patient willing to make a quit attempt, offer medication and
provide or refer for counselling or additional treatment to help the patient quit.
5. Arrange follow-up. For the patient willing to make a quit attempt, arrange for follow-up contacts,
beginning within the first week after the quit date.

Prevention of Oral cancer and Traumatic dental injuries.pdf

Motivational Interviewing
Phase 1! Quick assessment
– Rapport: “What sort of smoker are you? Tell me a bit about your smoking?” “You
may well be a little fed up with people lecturing you about smoking. I’m not going to
do that, but it would help me if I understood how you really feel about your
smoking…
– Motivation to quit: “If on a scale of 0 to 10, 0 is not at all motivated to give up
smoking and 10 is 100% motivated to give up, what number would you give yourself
at the moment?’
– Confidence in ability to quit: “If you were to decide to give up smoking now, how
confident are you that you would succeed? If on a scale of 0 to 10, 0 means that you
are not at all confident and 10 means that you are 100% confident you could give up
and remain a non smoker, what number would you give yourself now?”
•

Phase II: Patient identifies problems and solutions
If it’s a problem, always deal with motivation first
Motivation
Useful questions:
“Why are you at (chosen number) and not at 0?”
“What would need to happen for you to get from (chosen number) to (higher
number)?
Confidence
Useful questions:
“Why are you at (chosen number) and not at 0?”
“What would need to happen, for you to get from (chosen number) to (higher
number)?
“How can I help you get from (chosen number) to (higher number)? If no ideas
come from patient, offer range of possibilities

Phase III: Target and follow up
 Target: Reinforce value of small gains and openness. Can patient set manageable
goal?
– May relate to numbers of cigarettes smoked (not to increase, to cut down or quit)
– May relate to factors that influence smoking, such as relationships, weight, exercise
 If not ready to set any sort of target, keep communication open: “Things do change … Can
we agree to leave the door open on this one?”
 Follow up:
– Find out how best they think you can help them attain their target. Ideas could
include follow up visits,
– telephone calls, advice on nicotine replacement (for those with definite signs of
nicotine addiction only).

Barriers to quit smoking
• Time constraints in clinical practice
• Clinician’s own smoking
• Inadequate institutional/systems support for routine assessment and treatment
• Clinician’s lack of knowledge of:
 Chronic nature of nicotine addiction
 How to identify and treat tobacco users
 Est. that 63-190 thousands smokers would stop if clinicians offered smoking
cessation advice
 Which treatments are efficacious

Public health approaches using action areas of HP (Ottawa Charter) to prevent oral cancer
1. Building Heath Public Policy  Anti-tobacco smoking Act
 Ban advertising
 Fiscal policy; increase taxes on Tobacco
 Subsidize NRT
 Picture-based warnings
 Ban deceptive labels (mild, light)
1. Create Supportive
Environment
 Create smoke-free public spaces
 Increase availability of 5 portions of fruit a day- sch canteens/shops
 Easy access to NRT
1. Strengthen Community
Action
 Smoking cessation support groups
 Establish QUIT LINES which are user friendly to most smokers
 Support establishment that sell cheap healthy fruit & veges
1. Develop Personal Skill  Extend health and social education to schools –life empowerment to schools, coping skills
and resisting peer pressure, self-awareness & self-confidence lessons.
 Incorporate tobacco and alcohol control initiatives within schools
 Indiv 5 “As”-assist quiting
1. Reorient Health Services  Empower or expand knowledge of smoking cessation & alcohol control to health
professionals.
 Increase number of health promotion prof experts within the health system
 Establish evidence-based smoking & alcohol preventive services within the PHC system
 Allocate time and provider remuneration for smoking cessation to increase incentive

Tobacco control in South Africa
• • Pre 1993
– – No tobacco control policy.
• • 1993 Legislation
– – Introduced warning labels on packaging and advertising
– – Allowed for restrictions on smoking in public places
– – Banned sales to under 16s.
– – increases in excise taxes Tobacco control in South Africa
• • 1999 Legislation
– – Bans smoking in indoor public places
– – Bans all advertising, promotion & sponsorship of tobacco
– – Bans free distribution of products
– – Limits the maximum yield on tar, nicotine & other ingredients
• • 2007/8 Legislation
– - Bans smoking in cars with children under 12 and in selected outdoor
areas.
– - Controls chemicals that may be emitted or added to tobacco
• Self-extinguishing cigarettes
• Picture-based warnings
• Ban deceptive labels (mild, light)
Call the Quit Line
“MAKE A FRESH START “
Change your life for the better
011 720 3145

Common Risk Factor Approach
Work
Place
Housing
Risk
factors
Tobacco
Alcohol
Exercise
Injuries
Social
environm
ent
Diseases
Obesity
Cancers
Heart diseases
Respir. dis
Dental Caries
Perio
dis.
Trauma
Physical
environme
nt
Risk
factors
Diet
Stress
Control
Hygiene
Political
environment
School
Policy
Modified from Sheiham & Watt , 2000

Prevention of Traumatic Dental Injuries (TDIs)

• TDIs extends from the chipping of teeth to more extensive oral injuries
• Generally, injuries are a major cause of mortality & morbidity world wide
• TDIs are a Common Public Oral Health Problem -12 yr review in SA (Glendor,
2009)
TDIs
UK
• Claims 1/3 of deaths amongst the youth [15-24 in UK]
• Injury claims over 10000 lives p.a
• 3000 aged >65 die from falls
• Children from poor families more susceptible than those
from professional families
• Expensive to treat and costly burden on government fiscus
UK
• Claims 1/3 of deaths amongst the youth [15-24 in UK]
• Injury claims over 10000 lives p.a
• 3000 aged >65 die from falls
• Children from poor families more susceptible than those
from professional families
• Expensive to treat and costly burden on government fiscus

Epidemiology of TDIs in SA
• The prevalence of TDIs in SA
schoolchildren is 6.4% for 11- to 13-year
olds
• Boys having a higher prevalence than
girls { greater participation in contact
sports, fights}.
• Usually affect lower socio-economic
classes
• Most of the TDIs occurred at more
home than at school. [In schools that
have a supportive social/physical
environment, ]
• Falls , sport, collision were the most
common reason for the TDI.
• 20-80% of all injuries & admissions in all dental
clinics and hospitals= high prevalence
• Among hospital presentations, intentional injuries
(such as assault) ≈ approx 16 %
• Road traffic accident was the common cause for
maxillofacial injuries.
• Men injured more than women. Female: male ratio
was 1:6.
• Young more affected than old (78% 20--39 years.)
• Influence of alcohol at the time of injury was found in
about 58% of the patients with maxillofacial injuries.
• The most number of accidents occurred in the
weekends.
• There’s a relationship between facial trauma, poverty
and alcohol consumption.
• Trauma due to interpersonal violence  midface
injuries.

Impact of TDIs
• Minor (cracks, tooth fracture) to major injuries (tooth luxation to
bone fractures)
• With decline in caries in developed countries, Cost of treating TDIs
may soon equal that of caries [‘cos of caries decline]
• Costs vary depending of complexity [contained within dental clinic to
multidisciplinary/specialists]
• Expensive and complicated to treat (specialists & several
disciplines).
• Length of treatment may continue for rest of life.
• alter facial appearance/ self-confidence
• Affect a person’s QOL,

Aetiology
• Socio-environmental
– Contact sports
– Violence- abuse
– Falls
– Traffic accidents
– Poor environments-overcrowding [social class]
• Clinical- limited effect
– Orthodontic 1-5%
• Incisal protrusion
• Increase overjet (>6mm)
• Incompetent lips- inadequate lip coverage
– Iatrogenic 12%– anaesthetic (major cause of
claims/litigation in UK)
• Behavioural
– Traumatic habits, risk-taking
– Presence of illness, learning difficulties or physical
limitations
Limitations of clinical
approach
• Time
– Long term effects of
treatment
– Clinical time
• Lack of clinical expertise
• Poor Rx outcomes
• Accessibility : inequitable
• Palliative vs. addressing the
causes of condition
• Potential to have long lasting
solutions
• Time
– Long term effects of
treatment
– Clinical time
• Lack of clinical expertise
• Poor Rx outcomes
• Accessibility : inequitable
• Palliative vs. addressing the
causes of condition
• Potential to have long lasting
solutions
Public Health
Approach

Are they preventable?
• There is little agreement in the literature whether TDIs are preventable.
• Traditionalists hold a view that TDIs are unavoidable accidents.
• However, some situations :
– oral (e.g. excessive overjet of maxillary teeth),
– environmental and
– human factors (e.g. unsafe playgrounds and high-risk sports).
• Prevention could be of benefit, particularly regarding severe TDIs.
• Change in attitude and behaviour were the most important factors to reduce severe TDIs.
– Improved supervision in school yards; use of mouth guard protection.
• Educational efforts directed specifically to children, parents, teachers and physical trainers may have the best
effect on the prevention of TDIs.
• Unfortunately, there is not enough scientific studies demonstrating the success of such educational efforts .

Public health approaches using action areas of HP (Ottawa Charter) to prevent TDIs
1. Building Heath Public Policy  Regulating physical availability policy regarding liquor outlets, :
 controls on access
 Allocating liquor licenses,
 Handling of complaints.
 ↑ taxation on alcohol products
1. Create Supportive Environment  Safe home & school environments to reduce accidents
 Implement effective Rx prog. for chronic drinkers –AA
1. Strengthen Community Action  Collaborate with other disciplines e.g. Arrive Alive campaigns
 Implement more effective drink-driving counter-measures (breathalizer, revoke driving
licence etc.) .
 Enhance social support
 Haddon’s matrix t: 3 Es of injury prevention (engineering, education/behaviour change
and enforcement)  sport and recreational injuries should be preventable
1. Develop Personal Skill  Extend health and social education to schools
 Life, empowerment & coping skills and resisting peer pressure, self-awareness &
self-confidence lessons.
 Use of mouth guards
1. Reorient Health Services  Strong and good referral systems for major injuries
 Increase number of health promotion prof experts within the health system = COMON
RISK FACTOR APPROACH
 Establish evidence-based alcohol preventive services within the PHC system

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