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J Am Dent Assoc, Vol 134, No 3, 307-314.
© 2003 American Dental Association
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RESEARCH

JADA Continuing Education

Characteristics of oral cancer in a central European population

Defining the dentist’s role



NILS-CLAUDIUS GELLRICH, D.D.S., M.D., MERCEDES M. SUAREZ-CUNQUEIRO, D.D.S., ANDREAS BREMERICH, D.D.S., M.S. and ALEXANDER SCHRAMM, D.D.S., M.D.


   ABSTRACT
TOP
 ABSTRACT
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Background. The authors conducted a study to evaluate the effectiveness of dentists in the early detection, treatment and postoperative care of oral squamous cell carcinoma, or SCC, in a central European population.

Methods. This multicenter retrospective study was conducted under the auspices of DÖSAK (a German, Austrian and Swiss cooperative group on tumors of the maxillofacial region). A questionnaire was used to evaluate the diagnostic, treatment and postoperative processes involved in managing the care of patients with oral SCC. A total of 3,894 questionnaires was sent to patients who had been diagnosed with and operated on for oral SCC at least six months previously; 1,761 questionnaires were returned. Another 1,652 additional questionnaires were sent to their oral surgeons; 1,543 were returned.

Results. The pT staging was pT2 (40.41 percent), pT1 (31.30 percent), pT4 (16.35 percent) and pT3 (11.90 percent). In 61.3 percent of the patients, there was no evidence of metastases. In 40 percent of the patients, the dentist treated the first symptoms, whereas the physician did so in 27 percent of the patients. A total of 72.5 percent of the dentists and 40.11 percent of the physicians identified oral SCC correctly.

Conclusions. Dentists should participate actively in oral cancer patients’ rehabilitation processes through regular clinical follow-up examinations and restoration of intraoral function.

Clinical Implications. Dentists should conduct an oral cancer screening at each patient visit. Patients who are at risk should undergo more intense surveillance. Dentists should advise their patients to stop high-risk habits such as smoking and help them make choices for healthier lifestyles.

About 4 percent of all malignant tumors in men appear in the neck and oral cavity.1 Over the last few years, little improvement has been made to improve the survival rate of patients with oral cancer. Although early detection is the fundamental factor for improving the survival rate,2–9 most malignant oral tumors are not detected until they are in advanced stages. Only 20 to 50 percent of patients who have oral cancer survive five or more years.10–12

Early detection of, diagnosis of and the initiation of therapy for oral cancer depend primarily on dentists.

Early detection of, diagnosis of and the initiation of therapy for oral cancer depend primarily on dentists. Dentists have a responsibility to screen for cancer in the oral cavity.13–17 They should conduct intraoral and extraoral examinations at every appointment15–18 and pay special attention to patients’ high-risk habits.18–25

We conducted this retrospective study to evaluate the effectiveness of dentists in the early detection, treatment and postoperative care of 1,761 central European patients who had and were treated for oral squamous cell carcinoma, or SCC, at least six months previously.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
We conducted this multicenter retrospective study under the auspices of DÖSAK, a German, Austrian and Swiss cooperative group involved with tumors of the maxillofacial region. We collected data regarding all aspects of diagnostic, treatment and postoperative processes in patients with oral SCCs. To qualify for participation in the study, patients had to have been diagnosed with and operated on for oral SCCs (lips not included) with or without other adjuvant therapies at least six months before completing the questionnaires. Members of the Oral and Maxillofacial Surgery Department and the Institute of Medical Psychology at Ruhr-University, Bochum, Germany, collaborated on the design of the questionnaires. We produced two questionnaires and sent them to two distinct groups: patients and the oral surgeons who had treated the patients.

We sent 3,894 questionnaires to patients through the oncology services of 34 participating oral and maxillofacial surgery departments in Austria, Switzerland and Germany. Of these questionnaires, 1,761 were returned anonymously within the time limit. The patients’ questionnaire included a total of 147 questions in seven categories: demographics, health behavior, course of the disease before admittance to the hospital, course of the disease before surgery, course of the disease after surgery, postoperative care and coping with disease.

In women, tumors were found most frequently on the tongue and the floor of the mouth.

We sent 1,652 questionnaires to oral surgeons by mail, and 1,543 of these were returned anonymously. The oral surgeons filled in the questionnaire based on the patient’s medical history. We included the categories of tumor location, pTNM staging, treatment, recurrence and rehabilitation in the questionnaire.

Not all of the respondents answered all of the questions. Thus, in the results section, the size of the sample used is based on the number of responses received regarding the specific aspect being analyzed.

We analyzed the data using a software package (SPSS Release 7.5 for Windows, SPSS, Chicago). The Institute of Medical Psychology at Ruhr-University, Bochum, Germany, created a complementary program to digitize the data. After we coded all of the data, we used specially designed software to detect mistakes in the oral surgeons’ and patients’ questionnaires. The program filtered the data to detect obvious mistakes. Through this filtration process, any possible bias caused by non-systematic mistakes was avoided. Furthermore, we conducted one control test per 10 questionnaires to correct any systematic mistakes observed in the questionnaire’s coding. Three people were responsible for this revision task. The statistical analysis included descriptive statistics and relevance tests, such as the t test and the {chi}2 test.


   RESULTS
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
Our results are summarized in Table 1Go and Table 2Go; Table 1Go presents the surgeons’ responses, and Table 2Go presents the patients’ responses. We determined the sample size by the number of responses received for each question.


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  		TABLE 1 DENTISTS’ RESPONSES TO THE QUESTIONNAIRE.

 

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  		TABLE 2 PATIENTS’ RESPONSES TO THE QUESTIONNAIRE.

 
Age and sex. The average patient was 60 years old; 66.7 percent of the sample was 50 to 70 years of age. Women were an average age of 62.60 years, and men were an average age of 58.20 years. The ratio of men to women was 3:1 (1,239:413).

Tumor location. We used the International Code of Diseases, ninth revision, to define the tumor location in each patient’s mouth. In 1,484 patients, the most common tumor locations were the floor of the mouth (code 144) (41.1 percent), the tongue (code 141) (24.3 percent), the gingiva (code 143) (16.7 percent) and in other nonspecific sites in the oral cavity (code 145) (14.1 percent).

When we analyzed tumor location according to sex, we noted that in men the distribution was identical to the sample as a whole. In women, however, tumors were found most frequently on the tongue (30.1 percent) and the floor of the mouth (27.3 percent).

Regarding the overall sample, tumor location was postcanine in 51.6 percent of patients, postmolar in 27.0 percent and precanine in the remaining 21.4 percent of the patients.

Distribution according to the pTNM staging system. We received 1,489 responses regarding pT staging and found that pT2 tumors (40.41 percent) and pT1 tumors (31.3 percent) were the most frequent. Among 1,475 patients, the pN staging showed no evidence of lymph node metastasis (pN0) in 61.4 percent. The pM staging for 1,187 patients showed distant metastases for only 0.7 percent of the patients.

The distribution of tumors according to pTNM staging differed when we took sex into account. Women were mostly in the less advanced stages, and men showed twice the frequency of distant metastasis.

Risk factors. The 1,599 patient responses regarding smoking habits indicated that 61.0 percent of the patients were heavy smokers (more than 10 cigarettes per day), 13.5 percent were light smokers (up to 10 cigarettes per day), and 21.0 percent were non-smokers. The 1,617 patient responses to questions about smoking cessation indicated that 47.5 percent of the patients were smokers at the time of surgery, 33.47 percent were smokers who had quit less than six months before surgery, and 19.03 percent were smokers who had quit more than six months before surgery.

Our analysis of alcohol consumption among 1,599 patients showed that 64 percent claimed to be regular alcohol drinkers at the beginning of the treatment. Of these 1,023 alcohol drinkers, 58.3 percent usually drank beer (average consumption was 1.6 liters per day; however, some patients drank up to 10 L/day). Only 9.8 percent of the patients drank wine (average 1.2 L/day, maximum 5.2 L). Approximately one-fourth (25.2 percent) drank liqueur (average 5.5 glasses per day, maximum 50 glasses). Only 6.7 percent of the patients drank other alcoholic beverages. Women (30 percent) drank less alcohol than men (75.6 percent).

Of the 1,584 patients who responded to the question on satisfaction with dental prosthesis before tumor therapy, 15.28 percent complained of frequent tender spots caused by the prosthesis, 11.21 percent complained of a bad fit, and 37 percent of the patients reported no problems.

From symptom to diagnosis. Of the 1,171 patients who reported visiting a dentist or family physician, 42 percent of the patients visited immediately after the appearance of the first symptoms, and 16 percent waited three months or more (Figure 1Go). We observed no variation with respect to sex.



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  		Figure 1. The period between the first appearance of tumor symptoms and the first visit to the oral surgeon (n = 1,171).

 
A total of 1,519 patients indicated which type of medical professional treated their first symptoms. Dentists treated first symptoms in 40 percent of the patients, followed by family physicians (27 percent) and oral and maxillofacial surgeons (23 percent). Women visited their dentists more frequently than did men.

Of the 1,519 patients specifying who had detected their oral tumor, 53 percent indicated dentists, 45 percent said themselves, and 26 percent said oral and maxillofacial surgeons. Women (52 percent) detected their own tumors more frequently than men (43 percent).

Dentists identified 72.5 percent of the tumors in the 608 patients they saw as malignant, while family physicians did so in only 40.11 percent of their 406 patients. This difference was statistically significant (P < .001).

Of the 1,630 patients who responded that they visited the dentist before a diagnosis of the oral SCC was made, 31 percent visited the dentist annually, and 9 percent visited the dentist quarterly (Figure 2Go). We observed no significant difference between men and women.



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  		Figure 2. Frequency of visits to the dentist before detection of oral squamous cell carcinoma (n = 1,630).

 
We correlated the frequency of dental visits and tumor staging. Patients who waited more than two years between visits had pT4 tumors (34.59 percent) and pN3 tumors (45.5 percent) significantly more often than did those who visited the dentist every six months (P < .05).

From diagnosis to therapy. We received 1,645 responses about the time elapsed between diagnosis and treatment. Twenty-four percent of patients were sent to the hospital-based oral and maxillofacial surgery service immediately after the diagnosis, 42 percent were sent within two weeks after diagnosis, and 22 percent were sent between two and six weeks after diagnosis. Only 6 percent were sent between six and 12 weeks, and the remaining 6 percent were sent more than 12 weeks after diagnosis.

Therapy. We received 1,475 responses regarding type of treatment; the most frequent choice was surgery (47 percent), followed by surgery plus radiation therapy (34 percent). Of the patients who received radiation therapy, 30 percent reported having received preventive measures with fluoride during radiation therapy.

Postoperative care. Recurrence. We received 1,534 responses regarding tumor recurrence. Of these, 22.1 percent of patients experienced tumor recurrence (18.1 percent after initial therapy, and 4 percent at the approximate time they were filling out the questionnaire). The correlation of initial tumor symptoms with visits to the oral surgeon and the correlation of diagnosis with start of the therapy reveal that the longer the latency period, the lower the chances of being disease-free (P < .05).

Anxiety about tumor recurrence. Of the 1,649 patients responding about anxiety associated with tumor recurrence, we found a fairly balanced proportion in all categories; the exception was the 6 percent who were fearful.

Postoperative follow-up. Of the 1,645 patients responding about postoperative follow-up examinations, 95.7 percent of the patients indicated that they regularly had follow-up examinations. The 1,670 respondents who specified who performed the follow-up examination revealed that 86.0 percent were provided by oral and maxillofacial surgeons in public health system hospitals. Dentists performed 17 percent of follow-up examinations.

Psychological support. Of the 1,561 patients who responded about the person they chose to speak with about their disease, 43 percent reported that they preferred dentists, followed by relatives (35.9 percent).

Postoperative dental status. We received 1,621 responses regarding dental status. The largest group was fully edentulous (42.9 percent). A full prosthesis in the maxilla was present in 35.9 percent of patients, while lower-jaw full prostheses and partial prostheses were present in similar proportions (slightly more than 20.5 percent of patients).


   DISCUSSION
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
Population studied. The age and sex distribution of the patients in our study coincides with those in similar studies.21,26,27

The distribution of the oral SCCs according to the pTNM staging system revealed that more than two-thirds of the oral tumors were more than 2 centimeters in diameter at the start of therapy. In almost 40 percent of the patients, we also observed a lymph node metastasis. This high percentage may be explained by patients’ inattention to or unawareness of symptoms, leading to a delay in the initiation of therapy.

The results also reveal that women are more worried about tumors than men are. As a result, oral SCCs in women were detected at earlier stages of the pTNM staging system than were those in men. Kowalski and colleagues28 also observed this in a prospective study of patients with oral cancer. The paucity of distant metastases also is confirmed in this group of patients.

Dentists treated the patients in our study before the family physicians and maxillofacial surgeons did.

Some studies posit the association between the mechanical irritation caused by dental prostheses and tumor occurrence.29,30 In our study, however, only about one-fourth of the affected patients wore dental prostheses.

Regarding the distribution of risk factors, we noted a high incidence of heavy smokers and drinkers in our study. Research on this topic reveals that tobacco and alcohol consumption are associated strongly with the subsequent emergence of oral and pharyngeal tumors.27,31–35 Therefore, dentists should advise their patients to quit using tobacco and to adopt healthier lifestyles.

From symptom to diagnosis. In our study, the average time lapse between first noticing the symptoms and the first visit to the oral surgeon was 4.9 months, which is similar to the results in a study of Danish patients.36 This delay may indicate that the patients adopted a passive attitude or that the specialists who treated them failed to interpret their symptoms readily and correctly.28,37,38 Perhaps alcohol, with its analgesic effect, also helped suppress tumor-related pain and, thus, promoted passiveness in patients.

Dentists treated the patients in our study before the family physicians and maxillofacial surgeons did. Patients said that dentists play the most important role in early detection of oral cancer. In our study, dentists were responsible for detecting oral SCC in almost one-half of the sample. Considering the low levels of detection from family physicians and other specialists, the dentist’s role in the prevention of carcinomas gains importance. Dentists, therefore, should receive further training in the early detection of malignant tumors.39 Hahn40 also illustrated the important role of dentists in oral cancer detection compared with family physicians. In contrast, Schnetler38 discovered that family physicians diagnosed carcinomas and lymph metastases earlier than dentists did.

A study by Hall and colleagues41 emphasized the need for additional information. In a pilot survey of 500 randomly selected dentists, most were not well-informed about risk factors and oral cancer symptoms despite reporting that their knowledge of oral cancer was current.42 Negligence in this matter could have legal consequences.14

Some studies emphasize the importance of a partnership between dentists and family physicians43 to increase early detection of oral cancer. Dentists detect more oral cancer, but family physicians treat more patients who are at risk. During intraoral and extraoral examinations, dentists should pay special attention to people who use tobacco and people who drink alcohol, and family physicians should insist on regular dental checkups for patients who are at risk. With a more efficient partnership between dentists and family physicians, many tumors could be diagnosed at an earlier stage, resulting in an increased survival rate.44

In our study, more than one-third of the patients stated that they visit the dentist less than once a year. Since early detection of oral cancer depends on regular oral examinations, more frequent examinations are recommended for at-risk patients.29

From diagnosis to therapy. Most of the patients in our study started therapy within two weeks of diagnosis of an oral SCC. In contrast, Bruun36 reported an average lapse of 5.6 months between the first visit to the oral surgeon and the beginning of therapy. It is widely accepted that all patients with oral mucosal lesions should be referred to specialists, particularly if these lesions persist for more than two weeks.

Therapy. More than one-half of the patients received surgical therapy plus radiation therapy, chemotherapy or both. Preventive maintenance therapies for teeth, however, were used in only 30 percent of the patients who received radiation therapy. Dentists should play a key role not only in diagnosis, but also during and after treatment of patients undergoing radiation therapy and chemotherapy.

The postoperative follow-up. The frequency of recurrence of oral SCCs in our study group was 22.1 percent, compared with more than 50 percent in the literature.4 This may be explained by the exclusion criteria we applied (for example, dead patients were not taken into account). Our results also show that the high number of tumor-free patients coincides significantly with those patients who saw their oral surgeons immediately after onset of symptoms. The majority of these patients had stage pT1 tumors.

Specialists participated most in the follow-up of oral cancer patients, with family physicians next. Dentists took part in only 17 percent of this type of monitoring. If we consider that 43 percent of the patients preferred discussing the disease with their dentists (more often than with their relatives), then it follows that dentists are under-represented in postoperative care. This may be due to competition from specialists. Another reason may be that dentists are less confident about dealing with major resections and reconstructive surgery because they need more training in postoperative rehabilitation.

We maintain that dentists should be in charge of dental and periodontal patient care before, during and after radiation therapy. Dentists also should be involved in all aspects of prosthodontic care after surgical therapy to help the patient regain quality of life.45–48


   CONCLUSION
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
Dentists play a key role in managing the care of patients who have oral cancer. They are the providers most actively involved in the management of early symptoms, detection and diagnosis of carcinoma. Dentists should participate actively in an oral cancer patient’s rehabilitation process through regular clinical follow-up examinations and restoration of intraoral function. More training in this area is needed.



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  		Dr. Gellrich is a professor, Department of Oral and Maxillofacial Surgery, University Hospital of Freiburg, Hugstetterstr. 55, D-79106 Freiburg i.Br., Germany, e-mail "gellrich{at}zmk2.ukl.uni-freiburg.de". Address reprint requests to Dr. Gellrich.

 


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  		Dr. Suarez-Cunqueiro is an assistant professor, Department of Stomatology, University at Santiago de Compostela, Galicia, Spain.

 


   FOOTNOTES
 

Dr. Bremerich is a professor, Ruhr-University, Bochum, Germany, and head, Department of Oral and Maxillofacial Surgery, Zentralkrankenhaus St. Jürgen-Strasse, Bremen, Germany.


Dr. Schramm is a fellow in regional plastic surgery, Department of Oral and Maxillofacial Surgery, Albert-Ludwigs-University Freiburg, Germany.


The authors express their appreciation to DÖSAK for its support. In addition, they are grateful to the participating patients and to the oral and maxillofacial surgery departments that contributed their patients, time and efforts. The authors also would like to thank Dr. G. Krüskemper and Dr. E. Machtens for their great support.


   REFERENCES
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

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