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...of tobacco and alcohol use in patient medical histories, and opinions regarding tobacco and alcohol cessation education. Characteristics of dental hygienists who screen for tobacco and alcohol use in medical histories were also analyzed.
Methods. A 40-item survey was mailed to a simple random sample of 1,223 dental hygienists from a registry of 4,076 licensed in North Carolina. Data were included from 651 completed surveys, giving an effective response rate of 57%. Results. Most respondents correctly identified tobacco and alcohol use as risk factors for OPC. A majority assessed patients' tobacco and alcohol use. Less than 10% assessed no tobacco factors, while nearly 42% assessed no alcohol factors. A number of background and practice characteristics were found to be positively associated with tobacco and alcohol screening in patient medical histories. A majority agreed or strongly agreed that dental hygienists should be trained to provide tobacco and alcohol cessation education to their patients; however, few felt trained to provide such education.
Conclusion. Improvements in knowledge regarding tobacco and alcohol use as OPC risk factors are needed. Future interventions might include educational programs for currently practicing dental hygienists and increased tobacco and alcohol cessation education in the professional entry-level dental hygiene curricula.
Keywords: Tobacco, tobacco use cessation, alcohol, dental hygienist, professional education, medical history, oral cancer
Introduction
Oral and pharyngeal cancer (OPC) is the 12th most common type of cancer in the world and accounts for approximately 3% of all cancers in the United States. (1,2) The most common form is squamous cell carcinoma, which accounts for 96% of all oral carcinomas. (3) Etiological factors include tobacco use, alcohol consumption, a diet poor in fresh fruits and vegetables, infective agents, immune deficiency, and exposure to sunlight (lip cancer). (4) The two major risk factors, the use of tobacco and excessive alcohol consumption, combined are estimated to account for 75% of all cases in the United States. (5) Patterns and risks associated with tobacco and alcohol use have also been shown to account for nearly all of the observed racial differences in incidence and mortality rates. (6)
The age-adjusted (world standard) incidence rate for OPC was 8.1 per 100,000 population from 1995 to 1999, but it varied greatly according to race and sex. (7) In 2002, estimations of OPC were 28,900 new cases and 7,400 deaths in the United States. (8) North Carolina is the 11th most populous state and ranks 14th among all states in age-adjusted mortality rate for OPC. (8,9)
Preventable oral diseases compromise the health status of many Americans. Oral health care providers have the opportunity to become more involved in preventing or reducing the occurrence of these diseases. Dental hygienists, in particular, can serve as valuable resources for promotion of sustained oral health through prevention and early detection of oral cancer. The following research provides information about dental hygienists' assessment of tobacco and alcohol use in patient medical histories and is intended to help in the design of interventions to improve overall oral cancer control.
Review of the Literature
Many factors have been related to the development of OPC. Accepted modifiable behavioral risk factors for this disease include tobacco use, excessive alcohol consumption, over-exposure to the sun (for lip cancer), and a diet low in fruits and vegetables. In addition, a recent association of human papillomavirus with oral cancer has been established. (10) Some factors that have been erroneously associated with increasing oral cancer risk include hot foods and beverages, spicy foods, obesity, poor oral hygiene, poor fitting dentures, familial clustering, and family history. (11)
The strongest risk factor for oral cancer is the use of inhaled or smokeless tobacco and chewing substitutes that usually contain tobacco, such as pan masala or betel nut quid (common in some Middle and Far Eastern countries). (12) Risk associated with cigarette use, in particular, grows with increased consumption, and studies have shown that, for both men and women, increased tobacco use tends to increase oral cancer risk. (13-16) Tobacco smoking was found to be the leading risk factor for all of the cancers analyzed in one study, with both current and former use seen as harmful. (13) Another study concluded that a decrease in very high levels of cigarette and cigar smoking is key to overall oral cancer prevention. (14)
The results of a study involving 100 cases and 47,773 controls indicated tobacco chewing as a strong risk factor for erythroplakia. (15) Chewers who swallowed the tobacco fluid and chewers who kept the chewing tobacco in their mouths overnight both had higher risks for erythroplakia than chewers who did not swallow or orally store tobacco fluid. A dose-responsive relationship for the frequency of chewing tobacco with the risk of erythroplakia was seen. This study also indicated alcohol use as a strong risk factor for erythroplakia, showing a dose-responsive relationship for the frequency and duration of alcohol use with the risk of erythroplakia. (15)
Alcohol Consumption
Excessive alcohol use has been associated with oral cancer as a risk factor, and studies have shown that alcohol consumption may be involved in a multiplicative interaction with smoking. (16) Alcohol may possibly act as a solvent, allowing the carcinogens from tobacco to penetrate into the tissues, or it may act as a catalyst in metabolically activating tobacco carcinogens. Another possible mechanism is that alcohol lessens the protective effect of fruits and...
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