Dental Tribune United Kingdom Edition

6 Interview United Kingdom Edition October 2013 D ental Tribune Online: A recent study on Turk- ish dental patients in central Anatolia has shown that only one in two people are aware of oral cancer. Are these results representative of most people’s knowledge about the condition nowadays? Prof Stephen Porter: It is not uncommon for individuals not to be aware that cancer can arise in the mouth. Indeed, there are studies indicating that even pa- tients without cancer who attend clinics that specialise in mouth cancer are unaware of the possi- bility. This trend regarding a lack of awareness occurs across the globe, although it varies between countries. With celebrities such as Mich- ael Douglas struggling pub- licly with the disease, do you think awareness of malignant diseases of the mouth is in- creasing? Undoubtedly, it will increase. When a celebrity announces that he or she has a particular disor- der, there is often an upsurge of referrals by concerned individu- als. In the UK, this was perhaps best illustrated when Freddie Mercury declared that he had HIV. There was a substantial rise in the number of persons seeking advice and/or testing for the dis- ease in the aftermath. A fair number of famous peo- ple have had oral cancer, includ- ing Sigmund Freud, Ulysses S. Grant and TV producer Aaron Spelling to name but a few. In the UK, journalist and first hus- band of TV cook Nigella Lawson John Diamond wrote a series of articles detailing the progress of his disease and its treatment that informed many of the impact this disease can have on an individu- al and his or her family. Unfortunately, the Michael Douglas situation has perhaps confused the exact role of the human papillomavirus (HPV) in mouth cancer. Certainly, it can cause mouth cancer and it can be acquired through orogenital contact, but there is no evidence that such contact will lessen any subsequent risk of contracting mouth cancer. Oral cancer figures are rising worldwide. What are the rea- sons for this, and does it fulfil the criteria for an epidemic, as it has been called in some me- dia reports? An epidemic is defined as new cases of a disease in a given hu- man population over a particular period. It often has an emotive element to it. Oral cancer cer- tainly is on the increase in the developed world, although the number of new cases is falling in some parts of the globe, notably parts of India. The rise in some countries is gradual but sustained. Smoking tobacco and/or drinking alcohol are the two factors that tradition- ally have given rise to mouth can- cer. In addition, individuals are now acquiring cancer-causing (oncogenic) types of HPV, prob- ably via orogenital contact. This burst of infectious disease, or in- deed sexually transmitted infec- tion, is not a new phenomenon, but it has become much more manifest in the last 30 years. So, what is new is probably that oncogenic types of HPV are just more common in the sexually ac- tive population than in the past. The exact risk that it carries is unclear but it has been sug- gested that the risk of HPV-relat- ed mouth and/or throat cancer climbs when someone has had more than nine different sexual partners. What other factors besides smoking, drinking and HPV are currently being investi- gated, and what is their malig- nant potential? People chew betel nut prepara- tions (eg paan masal and gutka) in parts of India, Pakistan, Bang- ladesh and surrounding areas. These cause initial fibrosis of the oral tissue, termed “submucous fibrosis”, which carries a high risk of causing oral cancer of possibly 30 per cent. Submucous fibrosis can arise even in young individuals and is irreversible, and thus patients are likely to have a lifelong risk of mouth cancer, even if they stop the causative habit. The nightmare scenario is that when examining a patient with submucous fibro- sis the mouth opening can be so small that a clinician may be un- able to see the cancer. Mouth cancer can also arise in patients who have rare genetic disorders, such as Fanconi anae- mia and dyskeratosis congen- ita, but the most common oral disorder that is considered to be potentially malignant is oral lichen planus. This is a global disorder that typically occurs in middle-aged and older women. It is a chronic immune disorder that may cause painless white patches that sometimes are ac- companied by painful erosions or ulcers. It affects about one to two per cent of the population and is the most common disorder to af- fect the lining of the mouth (the oral mucosa). It has been suggested that one-two per cent of patients with oral lichen planus will develop mouth cancer, but this risk is highly unpredictable because it does not appear to be consistent- ly associated with the duration or type of treatment of the lichen planus, nor the age or sex of the patients, nor their alcohol or to- bacco habits. The good news, perhaps, is that 98 to 99 per cent of patients with oral lichen planus will not contract mouth cancer. Isolated white or red patch- es on the oral mucosa (some- times termed “leukoplakia” and “erythroplakia”) have malignant potential as well, but these are actually uncommon, particularly the latter, compared with oral li- chen planus. Besides new treatment con- cepts, prevention remains the most effective strategy against oral cancer. Why do so many dentists still appear to over- look obvious signs of the dis- ease, and do current screening procedures have shortcom- ings? The great majority of patients ultimately found to have mouth cancer will have been referred to a specialist service because a dentist or other dental profes- sional will have noticed some- thing abnormal. He or she might not have known what it was, but they did the correct thing by re- ferring the patient to a specialist. Screening for possible mouth cancer is straightforward. It is just a matter of examining the neck and mouth carefully. How- ever sometimes dentists do not know what to look for, as they have probably never seen more than one type of oral cancer in their professional lives. Similarly, mouth cancer is Interview: ‘The patient should be told the truth’ Dental Tribune Online spoke with Prof Stephen Porter from the UCL Eastman Dental Institute about new risk factors and prevention strategies for oral cancer Prof Stephen Porter, Director and Profes- sor of Oral Medicine of UCL Eastman Dental Institute