Oral Cancer - Only this month we too had to do a biopsy on a patients mouth and it is all part of the service.

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Ayubowan, betel chewing and oral cancer
(Daily News) Charmaine Fernando
The wise old sage in the village chewed betel. The school master did it, the village doctor did it. The people who looked up to their wisdom for advice believed it must be good. It over-powered their breadth mitigating foul smells at a time when toothpaste was yet to be discovered. When they had no cake to serve they plucked betel off the wine, arecanut off the tree in the garden and tobacco leaves from the adjoining chena and proved their degree of hospitality, proudly, beyond all boundaries. They never knew their hospitality will lead them to the hospital sooner than later.

Villagers never suspected oral cancer would creep in from behind their pleasant ‘chit chat and chew’ to wipe away their smiles. Oral Cancer happened then; it happened in the nineties but believe me the Sri Lankans are so steeped in culture, even in the second decade of the twenty first century, they are willing to die for it!

Cultural practice of betel chewing
Professor Prasad AmaratungaPix by Ruwan De Silva
In Sri Lanka betel is being served even before tea, in rural homes, as an extreme form of hospitality. There is no home in the village that won’t offer betel to a visitor. As per the cultural practice not offering betel is taken as an unwelcome gesture where the visitor takes offence.
Betel is the first offering students make to the teacher on the first day of school. No wedding, funeral or gathering is complete without betel chewing. Betel has become an integral part of the ritual, deep-rooted in the cultural practices of the Sri Lankan, from greeting to meeting and the people attach significance to this auspicious act of offering betel to one another. Breaking the habit for health sake will be an act of doing away with an age old custom of the Sri Lankans. How successful we can be in doing so is anybody’s guess.

The use of tobacco in the form of chewing with betel and arecanut has been a widespread habit among Sri Lankans since ancient times. Historical evidence shows that during the British rule 1823-1948, tobacco was an important commercial crop and was grown mainly in the northern part of Sri Lanka.

Today, thousands of rural farmers grow tobacco in their lands by replacing their traditional food crops. Cigarettes, beedi and cigars are the three main types of tobacco smoking products that are used by the people in Sri Lanka. During the Second World War period, the use of cigarettes increased significantly among Sri Lankans and, at present, smoking is a widespread male habit.
Bad habits can kill

Oral Cancer can occur in any part of the mouth, tongue, lips, throat, salivary glands, pharynx, larynx, sinus, and other sites located in the head and neck area. These ‘Mouth Cancers’ have a higher proportion of deaths per number of cases than breast cancer, cervical cancer or skin melanoma.

Oral and pharyngeal cancer is the sixth most common malignancy reported worldwide and one with high mortality ratios among all malignancies. The global number of new cases was estimated at 405,318 about two-thirds of them arising in developing countries. Highest rates are reported in South Asian countries such as India and Sri Lanka.
loss of tooth due to caries

The Indian sub-continent accounts for one-third of the world burden. The incidence and mortality from oral cancer is rising in several regions of Europe, Taiwan, Japan and Australia. Every year in Europe, around 100,800 people are diagnosed with head and neck cancer and almost 40,000 die from the disease.

In the USA alone, 30,000 Americans are diagnosed with oral or pharyngeal cancer each year. About 90 percent of head and neck cancers are of the squamous cell variety. Although there have been significant improvements in chemotherapy and surgical techniques, the disease is often particularly challenging to treat since most patients present with advanced disease, have secondary tumors and suffer from other health complications.

Poverty and tobacco
The use of tobacco has become a worldwide epidemic. According to WHO estimates, each year tobacco kills nearly 3.5 million people across the world. Smoking as well as oral use of smokeless tobacco is widely prevalent in South Asian countries. Studies conducted in India and Sri Lanka have shown that the habits of tobacco chewing and smoking are highly associated with oral cancer and pre-cancer with oral cancer being one of the commonest cancers in Sri Lanka.
At present, tobacco causes an estimated annual loss of US$100 billion to the economy of the developing world. This amount is more than 50% of the total annual health expenditure in those countries.

The worst affected are the families of smokers in the lowest socio-economic groups where a greater proportion of the family income is spent on tobacco, thus widening the gap between the rich and the poor in many third world countries, including Sri Lanka.

The burden of ‘Oral Cancer’
The Daily News spoke to Professor Prasad Amaratunga, Dean of the Faculty of Dental Sciences, University of Peradeniya and President Elect , Asia Pacific Dental Federation and APRO, who is also Chairman, Organizing committee, Asia Pacific Dental Congress 2010, due to be held at the BMICH Colombo in May.

Q: When it comes to oral health what major problems do you find in Sri Lanka?
Cancer outgrowing through the neck from the mouth cavity
A: There are three main areas of oral health we focus on, mainly dental caries, gum disease and oral cancer. I insist here, that dental caries and gum disease are preventable and oral cancer is a 100% curable, provided it is detected earlier-on or in the pre-cancer stage.
Dental caries is a bacterial disease and causes considerable disabilities. WHO recognized oral disease as a disease of great significance and appointed a sub-committee to focus its attention upon the subject.

One of the main reasons was the irregular attendance of students at school due to dental caries. If left unattended dental abscesses would form and spread to other areas. tThe jaw bone too can get affected. Gum diseases, inflammation, bleeding, abscesses, loss of bone, and ex foliation of the teeth would take place.

Q: Is there a way to create an attitude change of the people, as to the importance of dental health?
A: Many don’t attend to oral health because they don’t see or receive an immediate benefit. It is best to start them young at school going age to begin best practices and good habits. The Faculty of Dental Sciences holds educational programs for students and teachers of primary and nursery to create an impact over attending to dental care at a younger age.

Q: What are the Sri Lanka’s oral health statistics as at present?
A: The mouth is a small part of the entire body mass but oral cancer held an alarming 32 percent of all cancer patients in Sri Lanka. The number one killer is betel chewing with tobacco and arecanut that induce cancer. I count number two also as betel chewing insisting the importance of focusing attention and shedding some light in to this -not-so-seriously-concerned national issue. Thirdly I count smoking due to the damages it causes to the lining of the mouth.
Alcohol is the fourth culprit that leaves behind a half-baked inner-lining of the mouth. Lately the figures have gone down by 10 percent in Sri Lanka which is a good sign. This is due to the decline in numbers of youth refraining from smoking.
In India and South America they fo a step further to do ‘reverse’ smoking, having the lit up cigarette inside the mouth to avoid being noticed. The heat thus generated causes untold damage to the mouth’s inner lining.

Q: How do you find out whether you have an oral disease? Especially pre- cancer?
cancer on the lip
A: You will find a lesion from under the tongue. Oral cancer arises from a recognizable change, in colour. Look out for a white patch, red patch or white and red patches in speckles. If a white patch remains for a long time under the tongue show your dental surgeon immediately. It’s crucial to detect sooner because oral cancer is curable when detected early.

Q: What steps have the SLDA taken to mitigate the situation of oral cancer in Sri Lanka?
A: Primary prevention is crucial. Before you contract the disease it is necessary to educate the public on how to prevent it. Secondary prevention is to treat during the progression of the disease to mitigate its impact on the human through spreading. We work closely with the Cancer Society. Dental Faculty works with the Kandy branch mainly.
There is a global health promotion currently held. FDI Unilever Global Oral Health Project is funded by the Dental Federation and Unilever International who are working together to achieve its objectives. The funding also covers school projects targeting the education of school children on oral health.

Lesions and white patches under the tongue
The Faculty of Dental Sciences go to the general public in the rural areas, especially covering the high risk communities living in the estates. Recognizing the risk factor all are mass-screened mostly without them knowing it. They are treated at the medical faculty Peradeniya and sent to hospital for extensive surgery. All these services and medical facilities are offered free of charge to the people.

The Faculty has a ready team of experts and the facilities to handle serious situations. It has been internationally recognized by the medical and dental committees for excellence. The Association of Oral and Maxillofacial surgeons hold a training program for O and M surgery.

Q: What about other countries in the Asian region? Is oral cancer prevalent there?
A: India has 40 percent oral cancer patients due to betel chewing. In the subcontinent, globalization has taken the people of Asia all over the world despite the change of environment, the habits have moved with them. Now betel chewing has been looked at as a global issue.
To reduce your chances of getting oral cancers avoid the following
* Not smoking or chewing tobacco
* Limiting alcohol consumption
* Having a healthier ‘low meat, low fat’ diet, rich in vegetables and fruit with servings of bread, cereals or beans everyday.
* A high proportion of oropharyngeal cancers in nonsmokers and younger adults have been associated with HPV. The mode of transmission may be frequent oral sex in adolescents and young adults.

Mouth Cancer in young people increasing!
In its very early stages, mouth cancers can be almost invisible making it easy to ignore. You can improve your chances of survival if the cancer is detected early and rapidly treated. It is important to have self-awareness and to perform regular, self-examinations to help in the early identification of the following symptoms:
* A sore or ulcer in the mouth that does not heal within three weeks
* A lump or overgrowth of tissue anywhere in the mouth
* A white or red patch on the gums, tongue, or lining of the mouth
* Difficulty in swallowing
* Difficulty in chewing or moving the jaw or tongue
* Numbness of the tongue or other area of the mouth
* A feeling that something is caught in the throat
* A chronic sore throat or voice change (hoarseness) that persists more than six weeks, particularly in smokers over 50 years old and heavy drinkers
* Swelling of the jaw that causes dentures to fit poorly or become uncomfortable
* Neck swelling present for more than three weeks
* Unexplained tooth mobility persisting for more than three weeks – see a dentist urgently
* Persistent (especially unilateral) nasal obstruction, particularly associated with mucus (clear, purulent or bloody) discharge causing difficulty breathing through nose
* Unexplained persistent earache
Pre-cancer lesions in younger individuals
* During the last three years a total of 80232 patients were admitted at NCI for continuation of treatment and investigations. The male female distributions of inward patients were 42.7% and 57.2% respectively. About 88.2 % patients were adult and 11.7% were children.
* In adults, malignancies of breast, leukemia and oral cancers were the leading malignancies. The top three malignancies among male were cancer of oral cavity, leukemia, and malignant neoplasm of lymphoid, heamatopoietic and related tissues, whereas in females they were cancers of the breast, cervix, and leukemia.
* The vast majority of the patients who become afflicted by oral cancer are from the less educated and economically poor section of the rural population of the country. As in India and other South Asian countries with high incidence of oral cancer, the habits of chewing betel quid with tobacco and arecanut and smoking beedi are highly prevalent in Sri Lanka. The disease is age-related and seen in the 40-70 age group.
*e-cancer lesions and conditions may be seen in younger individuals. This is alarming.
The importance of ral Cancer Screening
* Mouth Cancer kills one person every 3 hours in the UK because of late detection. An increasing number of young people are being affected and 25% of the cases have no associated significant risk factors.
* Oral cancer is the most common type of cancer in Sri Lanka. Statistics of the Cancer Institute, Maharagama, the only exclusive hospital in Sri Lanka for this malignant disease show that one third or 25 percent to 30 percent of all cancers affecting the population of Sri Lanka are oral cancers.
*Most patients with oral cancer in Sri Lanka present themselves for treatment only after the disease has advanced considerably. In most cases surgical reconstruction is the method of treatment and require highly trained manpower and considerable financial and material resources.
* All this means one thing; prevention and early detection of oral cancer should receive a high priority.
(Daily News)
January 11th, 2010