2_risk factors.ppt
TRANSCRIPT
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Module 2:
Risk Factors and
Prevention
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Major Risk Factors for
Oral Cancer are:
Tobacco use
Alcohol use
Age over 40
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Additional Risk Factors Linked
To Oral Cancer Include:
Exposure to UV radiation
Human Papilloma Virus (HPV)
Nutritional deficiencies
Oral lichen planus
Immuno-supression
Syphilis
Marijuana use
Chronic irritation
Chronic candidiasis
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Tobacco UseThe risk of oral cancer increases with the
amount of tobacco used and the
duration of the habit. All tobacco types are associated with oral
cancer, for example:
-cigarettes -cigars -pipes
-quid -snuff -chew
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Tobacco Risks
90% of patients with oral cancer use tobacco
Smokers have 6 times greater risk of developing
oral cancer than nonsmokers.
Tobacco users who regularly use alcohol are at
greatest risk
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Tobacco and Cancer Recurrence
According to the ACS (2004):
37% of patients who smoke after a first oral
cancer will develop another in the
oropharyngeal area.
Chances are that only 6% of these patients will
develop another cancer if they stop smoking
Illinois Department of Public Health (IDPH) Toll
Free Tobacco Quit Line is 1-866-QUIT-YES or
1-800-784-8937
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Statistics Of The Adult
Population Who Smoke
DO NOT0%
20%
40%
60%
80%
SMOKE
DISTRIBUTION OF THE ADULT
POPULATION BY GENDER
WOMEN
MEN
Men
Women
DISTRIBUTION OF ADULT
POPULATION
Do Not
77%
Smoke
23%
Smoke
Do Not
The percentage ofwomen who smoke hasincreased 300% in thelast 50 years.
Male to female ratio in 1950was 6 to 1; today the ratio is2 to 1.
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Current* Cigarette Smoking Prevalence(%), by Gender and Race/Ethnicity, High
School Students, US, 1991-2001
*Smoked cigarettes on one or more of the 30 days preceding the survey.
Source: Youth Risk Behavior Surveillance System, 1991, 1995, 1997, 1999, 2001, National Center for
Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 2002.
28
35
31
13
16
3230
11
14
23
40
37
12
28
33
4040
17
32
36
28
34
39 38
22
32
18
33
2726
0
10
20
30
40
50
White, non-
Hispanic Female
White, non-
Hispanic Male
African
American, non-
Hispanic Female
African
American, non-
Hispanic Male
Hispanic Female Hispanic Male
P r e v a l e n c e
( % )
1991 1995 1997 1999 2001
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Cigars Not A Safer Alternative
Cigar smoking has increased among young and middle-aged
white men (18-44) (higher than average incomes and
education.)
CDC reports cigar use among adolescents is higher than
smokeless tobacco.
Risk of laryngeal, oral or esophageal cancer is 4-10 times
higher than non smokers.
Cigar smokers who inhale deeply are 6 times more likely todie from oral cancer and 39 times more likely to die from
laryngeal cancer (ACS, 2004).
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Alcohol And Oral Cancer 75 – 80% of all patients with oral cancer drink
alcohol frequently
Alcohol may act as a solvent and allow
carcinogens from tobacco to more easily enter
oral tissues
Alcohol produces acetaldehyde as a by-
product, which is an animal carcinogen (NIDCR,
2004)
A combination of both alcohol and
tobacco provides the greatest risk of
oral cancer.
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Tobacco And Alcohol:
Deadly Combination
It is estimated that
tobacco smoking and
alcohol drinking
combined account for
approximately ¾ of all
oral and pharyngeal
cancers in the U.S.
(ACS, 2004)
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Age And Oral Cancer
95% of oral cancers occur in individuals over age40, and the average age of diagnosis is in the 60s
Because 1/3 of the U.S. population is now over
age 45, oral cancer will be a significant problem inupcoming years
Changes in biochemical and biophysical
processing occur in aging cells
Chemicals, viruses, hormones, nutrients, and
physical irritants further affect aging cells, and may
contribute to the development of oral cancer
Silverman, 1999
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Race And Genetics Link unclear
African-Americans have higher rates than other groups
Genetic factors may be at work
Differences in lifestyles and habits also have an impact
Differences in
access to care,
tendency to seek medical and dental care, and
education levels most likely contribute to higher ratesof later diagnosis of oral cancer (Silverman, 1999)
Mutation of the p53 gene under investigation (damage tocell’s DNA, growth and division)
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Gender And Oral Cancer
Oral cancer occurs more than twice as often in
males
The ratio of male to female cases was 6:1 in1950; today is about 2:1
One reason for the reduced ratio is theenormous increase during the past 50 years in
females who smoke
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Gender And Oral Cancer
The lifespan of women is
longer and may contribute
to the increase in oral
cancer among women
The number of women
over age 65 exceeds thatof men by nearly half
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Ultraviolet Light
& Lip Cancer UV exposure contributes to lip cancer
Fair skinned individuals at higher risk
30% of lip cancers occur in those with prolonged exposure
to sunlight
Lip cancer decreasing due to lip balm w/ sun screen
Lip cancer is also seen in pipe smokers at the site where the
pipe stem is held
Lip cancers readily seen
More likely to be diagnosed at earlier, treatable stage
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Diet And Oral Cancer
Nutritional deficiencies implicated as riskfactor
Diet low in fruits & vegetables implicated in
cancers of mouth, larynx, and esophagus
Diet low in vitamin A has been linked to oralcancer in some studies
Iron deficiency associated with Plummer-
Vinson syndrome causes an elevated risk forsquamous cell carcinoma of the esophagus,
oropharynx and posterior mouth (Regezi &
Scuiba, 1999).
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Viruses
Human papilloma virus (HPV) and herpes simplex(HSV) may play a role in oral cancer development
2/3rds of oral cancers have HPV DNA in their cells
DNA from Epstein-Barr, cytomegalovirus, herpes
simplex, and HVP detected in oral cancer
biopsies (NIDCR, 2004)
Viruses contribute to the oral cancer
transformation in the presence of other
contributing factors
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Oral Lichen Planus
Wickham striae, or interconnecting white lines,
are common in reticular lichen planus.
Lesions are usually on the buccal mucosa, butthe tongue and gingiva may also be affected.
Lesions may be erosive with
pseudomembrane-covered ulcerations and
erythema.
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Oral Lichen Planus
Findings from various studies indicate a riskof malignancy, particularly in the
erythematous areas of the erosive form.
Lichen planus is not presently classified as
precancerous, but further definitive studies
may prove otherwise.
A close examination of Lichen planus lesions
in patients with the disease is prudent.
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Immunosupression
Persons with AIDS and those undergoing
immuno-supression for organ or bone marrow
transplantation may be at increased risk for
various oral, head, and neck malignancies
(Neville, et al. 1995)
AIDS patients usually develop Kaposi sarcoma
and lymphoma, rather than squamous cell
carcinoma (Sapp, Eversole, and Wysocki, 1997)
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Chronic Irritation
Irritation may be caused by ill-fittingdentures and broken teeth or fillings
Chronic irritation does not initiate oralcancer, but it is possible it may hastensits progress
The debate as to chronic irritation as arisk factor is ongoing
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Candidiasis Chronic candidiasis has been implicated as a riskfactor in oral cancer.
Certain strains of Candida Albicans produce
nitrosomines, which are carcinogenic.
Definitive studies have not proven candidiasis
infection to be a causative agent, but it may have the
potential to promote the development of oral cancer.
Candidiasis may be superimposed upon a preexisting
leukoplakia.
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Relationship Between Cell Events and
Lesion Appearance
DNA
AdductsSmoking Environmental
Factors
Virus DietDNA Damage
Oral Leukoplakia [White Lesions]
Erythrop lakia [Red Lesions]
Premalignant
Oral Carcinoma Malignant
DNA Repair
DNA Content
Cell Growth
Apoptosis
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State of Prevention Science
•Discontinue smoking and alcohol consumption
(health professional/patient)
•Head and neck examination (health professional)
•Medical history (health professional)
• Improve diet: fruits and vegetables (health
professional/patient)
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Other Factors that Play a Role in
Prevention:
• Genetics
• Oral health
• Sexually transmitted infections
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Discontinuing Smoking and
Alcohol Consumption
•Tobacco Control-
•counseling
•behavior modification
(dentist/patient/specialist)
•Referral to other health practitioners-
•Oral Medicine
•Oral Maxillofacial Pathology
•Diet-
•Nutritional counseling
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Oral Cancer Examinations
Obtain annual oral cancer examinations
after age 40
Ask medical and dental providers for an
annual examination
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Tobacco
Tobacco cessation should be
recommended to all patients who use
tobacco products.
The accompanying Tobacco Control
Program will provide you with tobacco
cessation techniques to use with your
patients.
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Alcohol
People who drink alcohol and don’t use tobacco
are at a greater risk for oral cancer, but the
combination of the two is most deadly.
Most oral cancers could be prevented if peoplequit using tobacco in any form and quit heavy
drinking.
Quitting tobacco and limiting alcohol use sharply
reduces any risk of oral cancer, even after many
years of use.
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Nutrition
Consume a diet high in fiber
Consume enough folic acid, vitamins and
minerals
Eat at least five servings of fruits and
vegetables daily
Provide nutritional supplements for
individuals unable to intake adequate
quantities of food
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Alternative Cancer Treatments for Oral
Cancer Prevention and Treatment
Retinoids have been used
to:
•Prevent premalignantoral lesions
•Reduce the growth of
established oral
carcinoma
•Reduce formation of
second primary oral
cancer
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•Vitamin E has been shown to:
-prevent oral premalignant lesions
-enhance the anti-oral tumor capacity of
chemotherapy and other agents
-block the cancer formation activity of
tobacco carcinogens
•Vitamin E and PAH both form complexeswhich modify Phase I and II enzyme genes
expression and expression of endocrine
factors
DNA Damage
Decreased
DNA Repair Increased
then Decreased
DNA Content
Decreased
Apoptosis
Increased
Fewer Smaller
Oral Tumors
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Green Tea Effect on Smokers
Compared to Non-Smokers
Molecular and cellular effects of green
tea on oral cells from smokers: A pilot
study.Schwartz JL, Vikki B, Larios E, and
Chung FL.
Molecular Nutrition and Food Research. In Press, 2004.
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Background For Green Tea Study
•80 articles published showing green tea offers
protection against tumorigenesis including initiation,promotion and progression (skin, lung, liver, mammary,colon).
•Green tea contains-antioxidant, ”polyphenolics” (e.g.,epigallocatechin gallate (EGCG)).
•Studies in animals and cells point to a mechanism that
involves p53 induction of apoptosis.
•Delivery of tea polyphenols through a drink, leaves or
extract has suggested possible delivery systems to
reduce risk for oral cancer formation
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0
5
10
15
20
25
30
35
w eek 0 w eek 1 w eek 2 w eek 3 w eek 4
Weeks of Treatment
% o f
C e l l s
smoker 3
smoker 2
smoker 1
0
20
40
60
80
100
week
0
week
1
week
2
week
3
week
4
Weeks of Treatment
% o f
c e l l s smoker 1
smoker 2
smoker 3
B[a]P-N2-
dG
Adducts
8-OH-dG
Adducts
40
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0
10
20
30
40
w e e k 0
w e e k 1
w e e k 2
w e e k 3
w e e k 4
w e e k 0
w e e k 1
w e e k 2
w e e k 3
w e e k 4
Weeks of Treatment
%
o f C e l l s
smoker1
smoker2
smokers3
Cyclin D1 Caspase-3
0
5
10
15
20
25
30
35
40
45
w e e k
0
w e e k
1
w e e k
2
w e e k
3
w e e k
4
w e e k
0
w e e k
1
w e e k
2
w e e k
3
w e e k
4
Weeks of Treatment
% o
f C e l l s
smoker1
smoker2
smokers3
p53 DNA
(aneuploid)
Content
Cell Cycle
and
Apoptosis
Markers
Tumor
Suppressor
DNA Content
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Green Tea Study Summary
•Oral cytology in conjunction with
“chemoprevention” agents can be used to
monitor specific molecular events on acontinuous basis.
•Green tea polyphenols in some smokers can
reverse the effects of exposure to tobacco
smoke
(e.g., cell proliferation is slowed and
increased apoptosis is noted).
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Limit Sun Exposure
To help prevent lip cancer :
- Use lip balm containing sun screen
- Use wide-brimmed hats
- Avoid outdoor activities in midday when
ultraviolet exposure is at its peak
R t Th Si
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Report These Signs or
Symptoms to Doctor or Dentist: A sore or area in the mouth that does not heal
after 2 weeks
Persistent pain in the mouth
Persistent lump or thickening in the cheek
Sore throat or feeling that something is caught
in the throat
Difficulty chewing or swallowing
Difficulty moving the jaw or tongue
Voice changes
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Additional Signs and Symptoms:
Numbness in the tongue or other mouth area
Swelling in the jaw that causes dentures to fit
poorly or become uncomfortable
Loosening of the teeth or pain around the teeth
or jaw
Lump or mass in the neck Weight loss (unexplained)
Persistent bad breath
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Role for the Health Professional
•Screen patients at risk
•Provide dental care to improve response to
cancer treatment
•Treat oral complications
•Provide referral to other specialists
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Prevention A Key Role for the
Health Professional
•Health professionals will use oral cells to
- Screen for an array of genetic and moleculardisorders
- Assess prevention of tobacco related cancers
by various agents- Evaluate environmental carcinogens
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