Preventive Dentistry Third Year

1. Prevention Strategies
for Oral Cancer
Aiman A. Ali, DDS, PhD.
Associate professor Oral Pathology
and Medicine

2. How to prevent the occurrence of a disease?
A disease with simple etiology
 Causal factor
 Dental caries
Traumatic exposure
Chemical irritations
Thermal irritations
Fracture of the crown
Disease
Pulpitis
Multifactorial disease (dental caries or oral cancer)?

3. How to prevent the occurrence of a disease?
Etiology of oral cancer
 Smoking
If we want to prevent
 Chronic irritations
the occurrence of
 Chronic diseases
oral cancer we have
 Alcohol
to control all these
factors !!!
 Hereditary
Is it possible?
 Genetic aberrations
 Others such as viruses, diet…etc.

4. General statistics
 Thirty
percent of all cancer deaths are caused
by tobacco.
 Over 80% of lung cancer deaths are caused
by tobacco.
 The lung cancer death rate for men was 4.9
per 100,000 in 1930 and it has increased to
75.6 per 100,000 in the decade of 1990.
 Ninety-two percent of oral squamous cell
carcinoma are attributable to tobacco usage.

5. Statistics and incidence
The incidence of lung cancer is highly correlated with smoking.

6. Statistics and incidence

7. The tobacco plant
was first brought to
Europe in 1558 by
the Spanish
physician Francisco
Fernandes
Aiman A. Ali, DDS, PhD. 2008

8. Tobacco and related oral habits
 Smoking





Cigarette (normal, black, light, natural….)
Pipe
Water-pipe
Reverse smoking
Cigar
 Smokeless


 Passive
Snuff, Tombak and similar products
Chewing the tobacco leaves
smoking
Aiman A. Ali, DDS, PhD. 2009

9. Tobacco and related oral habits
 Smoking

Cigarette (normal, black, light, natural….)

10. Tobacco and related oral habits
 Smoking

Pipe

11. Tobacco and related oral habits
 Smoking

Water-pipe

12. Tobacco and related oral habits
 Smoking

Reverse smoking

13. Tobacco and related oral habits
 Smoking

Cigar

14. Tobacco and related oral habits
 Smokeless

Snuff, Tombak and similar products

15. Tobacco and related oral habits
 Smokeless

Chewing the tobacco leaves

16. Tobacco and related oral
habits
 Passive
smoking

17. Smoking any tobacco product,
*%, Males
* WHO Report on the Global Tobacco Epidemic, 2008

18. Smoking any tobacco product, %,
Females
* WHO Report on the Global Tobacco Epidemic, 2008

19. Constituents

"Chemical analysis shows the tobacco leaf/smoke to contain an
unusual number of constituents.
Nicotine,
Nitric,
phosphoric,
pictic,
nicotianine,
hydrochloric,
citric, acetic,
ulmic acids
tobacco acid or malic acid
sulphuric,
oxalic,
Acetaldehyde, acrolein, ammonia, carbon monoxide,
formaldehyde, hydrogen cyanide, hydrogen sulfide,
methyl chloride, nitrogen dioxide
And others: Benzopyrene, Tar, Naphthalene, arsenic and others
Hinds JID, The Use of Tobacco (Nashville, Tenn: Cumberland Presbyterian Publishing House, 1882), p 36
Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service, PHS Pub 1103, Chapter 6, Table 4, p 60 (1964)

20. Constituents
Chemical structure of the
carcinogen benzopyrene diol
epoxide
Benzopyrene, a major mutagen in tobacco
smoke, in an adduct to DNA*
* PDB 1JDG

21. Constituents

"Moreover, there is no question that arsenic . . . is definitely an
active carcinogen on human tissue. . . .

the arsenic content of American cigarettes has increased from two
to six times in a period of 25 years.

One popular American brand contains from 41 to 52.5 micrograms
of arsenic, of which one third remains in the butt, one third is in
the ash, and one third goes into the smoke.

About five micrograms of arsenic trioxide is inhaled from each
cigarette.
Alton Ochsner, Smoking and Your Life (New York: Julian Messner Pub, 1954 rev 1964), p 15.
A large sample of native arsenic.
Aiman A. Ali, DDS, PhD. 2008

22. Constituents

Cigarettes and other forms of tobacco are extremely addicting and
nicotine is the drug that causes that addiction

Pharmacologic and behavioral characteristics of nicotine
addiction are similar to those of heroin, cocaine, and
methamphetamine
Nicotine molecule

23. Nicotine

Absorbed by the lungs via inhalational route

Absorbed topically through skin and mucous lining of the
mouth

Rapidly distributed after inhalation and reaches the brain in as
little as 10 seconds

Mucosal absorption from smokeless tobacco is slower but more
sustained

Swallowed nicotine is not absorbed and eliminated from the
body

24. Nicotine

Following absorbtion, the elimination half-life of
nicotine is about 2 hours, thus it can accumulate with
repeated exposures over the course of a day

A typical smoker takes ~10 puffs of a cigarette over
about 5 minutes

Each cigarette delivers about 1 mg of nicotine

Thus, a person who smokes a pack a day (20
cigarettes) gets 200 hits of nicotine to the brain every
day, each one within 10 seconds after a puff

25. Physiologic and Behavioral
Effects of Nicotine

Increases heart rate

Increases cardiac output

Increases blood pressure

Suppresses appetite

Produces strong sense of pleasure and well-being

Improves task performance

Reduces anxiety

26. Nicotine Withdrawal

The effects of nicotine gradually diminish over a period of 30
minutes to 2 hours, and result in withdrawal effects

Dysphoria (disagreeable feeling) or depression

Insomnia

Irritability, frustration, anger

Anxiety

Difficulty concentrating

Restlessness

Decreased heart rate

Increased appetite

27. Effects of smoking and it’s quantity
1. Tobaco poisons are so powerful in miniscule quantities that
even smoking merely one cigarette can be enough to start the
fatal addictive process
2. See the article, "Lower Tar Makes No Difference," for an
example of why this is so.
3.
British Medical Journal, Vol 328, Issue # 7431 (10 January 2004)

28. Scope of the Problem in the
USA

21% of US citizens use tobacco products (mostly cigarettes)

440,000 deaths each year attributable to tobacco use; #1 cause of
death and disease

Heart Disease

Cancer

Stroke

Chronic Respiratory Disease

4,000 children and teens become regular users of tobacco each day

Direct medical care costs estimated to be $50 billion annually; loss of
productivity costs $47 billion

70% of smokers have made at least 1 attempt to quit or want to quit;
48% try to quit each year

29. Diseases Associated With
Tobacco Use

Cardiovascular Disease: 2-4x risk (coronary heart disease, myocardial
infarction, peripheral vascular disease {10x risk}, stroke {2x risk})

Pulmonary Disease 10x risk (emphysema, chronic bronchitis, asthma,
lung cancer {12-22x risk})

Pregnancy (stillbirth, spontaneous abortion, ↓ fetal growth,
premature birth, LBW, oral clefts)

Cigarette smokers die 13-14 years earlier than non-smokers

30. Oral Effects of Tobacco Use

Gingival inflammation and recession

Periodontal disease

Implant failure

Dry socket

Smoker’s melanosis

Nicotine stomatitis

Leukoplakia

Erythroplakia

Verrucous carcinoma

Squamous cell carcinoma

31. Oral Effects of Tobacco Use

32. 
Tooth staining

Tooth abrasion (chewing tobacco)

Halitosis

Hairy tongue

Diminished taste and smell

33. Benefits of Quitting

20 Minutes After Quitting: Heart rate drops.

12 hours After Quitting: Carbon monoxide level in blood drops to normal.

2 Weeks to 3 Months After Quitting: Heart attack risk begins to drop.
Lung function begins to improve.

1 to 9 Months After Quitting: Coughing and shortness of breath decrease.

1 Year After Quitting: Risk of coronary heart disease is half that of a nonsmoker’s.

5 Years After Quitting: Stroke risk is reduced to that of a nonsmoker’s.

10 Years After Quitting: Lung cancer death rate is about half that of a nonsmoker’s. Risk of cancers of the mouth, throat, esophagus, bladder,
kidney, and pancreas decreases.

15 Years After Quitting: Risk of coronary heart disease is back to that of a
nonsmoker’s.

34. ?What Can We as Dentists Do

“Gold Standard”; the 5 A’s

Ask

Advise

Assess

Assist

Arrange

35. ASK

Ask every patient about their
tobacco use:

Current use?

How long used?

Form of tobacco used?

Quantity used daily?

If former user, how long
quit?

Ask if they have considered
quitting or are interested in
quitting

Ask about previous attempts to
quit and reasons for failure

36. ADVISE

Urge the tobacco user to quit, but don’t badger or shame them

Relate their tobacco use with their oral condition (periodontal
disease, lesions, halitosis, taste complaints)

Emphasize the benefits of quitting

Tell your patient that you will help them if they want to quit

37. ASSESS

Asses readiness to quit


be professional, gently persistent, and supportive
Ask directly: “Are you interested in quitting?”

If so, move on to the assist phase

If not, drop the subject, but continue to provide
motivational intervention at every opportunity

Be alert for “teaching moments”

38. ASSIST/ARRANGE

Provide self-help materials

“You Can Quit Smoking”

“Benefits of Quitting”

Refer patient to a counseling source (telephone help line)

Coordinate a smoking cessation program for the patient


Provide NRPs or medications for the patient if desired
Refer patient to a smoking cessation program

39. Outcome of the 5 A’s

Not good!

Most dentists and physicians are unaware of the initiative

Reasons cited for not engaging in the activity:

Takes too much time

Lack of training

Lack of reimbursement

Lack of knowledge about available referral sources

Lack of patient education materials

40. Difficulty Quitting

The more cigarettes smoked, or the more smokeless tobacco
used, the harder it is to quit

The longer a person has used tobacco products, the harder it is
to quit

The more tobacco usage is incorporated into daily activities, the
harder it is to quit

41. Nicotine Replacement Products

Nicotine patch (Nicoderm; Nicotrol: OTC)

Nicotine gum (Nicorette; OTC)

Nicotine lozenge (Commit; OTC)

Nicotine inhaler (Nicotrol; Rx)

Nicotine nasal spray (Nicotrol NS; Rx)

42. Use of Nicotine Replacement Products

Smokers need to maintain a blood level of nicotine around 15-18
ng/ml in order to prevent withdrawal symptoms

A single cigarette increases blood level of nicotine to 35-40
ng/ml

After about 25-30 minutes, the blood level falls back to 15-18
ng/ml

NRPs aim to provide a steady blood level of around 17 ng/ml in
order to prevent withdrawal symptoms

The patient then progressively learns to accept smaller and
smaller blood nicotine levels and then ultimately zero

43. NRT: Nicotine Transdermal Patch
((Available OTC

Nicoderm CQ; Generic; 3 strengths (21mg, 14mg, 7mg)

Nicotrol; 1 strength (15mg)

Dosages:

Nicoderm CQ or generic
 1-21mg
patch/day for 6 weeks, then
 1-14mg
patch/day for 2 weeks, then
 1-7

mg patch/day for 2 weeks
Nicotrol
 1-15mg

patch/day for no more than 16 hours
per day for 8 weeks

44. NRT: Nicotine Polacrilex (Gum)
((Available OTC

Nicorette; 2 strengths (2mg and 4mg)

Chewed briefly, then “parked” for 30 minutes; good control;
clock regulated better than prn

Dosage:

use 4mg gum up to 24 pieces per day; 2 weeks at 12/day,
then 1 week at 10/day, then 1 week at 9/day, etc.

45. NRT: Nicotine Lozenge
((Available OTC

Commit; 2 strengths (2mg and 4mg)

Parked between cheek and gum; periodically moistened by
placing on tongue and wetting with saliva

Provides 25% higher blood levels than gum

Absorption results in blood level of 86% of dose, but swallowing
results in only 2% of dose

Dosage:

Use 12 - 4gm lozenges per day, 1 about every 80 minutes;
maximum 20 pieces/day

46. NRT: Nicotine Nasal Spray
*Prescription only

Nicotrol NS

Rapidly absorbed; produces good nicotine blood levels; good
control

Good choice for very dependent user

Dosage:

8-40 doses/day for 3-6 months

A dose is 1 puff/nostril (6ng/ml)
3
doses/hour for 2 weeks, then
2
doses/hour for 4 weeks, then
1
dose/hour for 4 weeks

47. NRT: Nicotine Inhaler
*Prescription only

Nicotrol inhaler (cartridges)

Similar to smoking; rapid absorption

Generally not able to achieve optimum blood nicotine levels; not
the best choice for very dependent users; very
ineffective; expensive


Dosage:

6-16 cartridges/day for up to 6 months

48. Non-NRT Pharmacotherapeutic Agents

FDA Approved for smoking cessation



Bupropion (Zyban)
Varenicline (Chantix)
Non-FDA approved

Nortriptyline (Pamelor)
 tricyclic

antidepressant
Clonidine (Catapres)
 α-2
adrenergic agonist; antihypertensive

49. Bupropion SR (Zyban)
*Prescription only

Zyban; an antidepressant (Wellbutrin) but in a sustained release
form

As effective as nicotine patches when used alone

1 year quit rate about 10-15%

May be additional benefit when used in combination with other
NRT

Dosage:

150mg tablets

Start 1-2 weeks before quit date

Take a 150mg tablet QD for 3 days, then BID thereafter;
continue for 7-12 weeks; may need to continue for up to 6
months

50. Varenicline (Chantix)
*Prescription only

Chantix; a unique medication that partially activates nicotine
receptors to reduce the severity of craving for cigarettes and
withdrawal symptoms

Doubles the likelihood of quitting over bupropion and
quadruples it over placebo

1 year quit rate with varenicline alone is 22%

Dosage:

0.5 and 1.0 mg tablets

Start 1 week prior to quit date

0.5 mg daily for 3 days, then 0.5 mg twice a day for 4 days,
then 1.0 mg twice daily for 12 weeks