Earn1 CE credit

This course was written for dentists, dental hygienists,

and assistants.

Diet and Oral CancerA Peer-Reviewed Publication Written by Jeff Burgess, DDS, MSD

AbstractThe relationship between diet and oral cancer is complex and not fully understood at present. A number of foods and food products have been associated with the development of oral cancer and some foods, nutrients, and supplements have been linked to cancer prevention. This course briefly reviews some of the current nutrition science assessing relative risk and the prevention of oral cancer.

Learning Objectives:At the conclusion of this educational activity participants will be able to:1. Describe the foods that increase or

decrease oral cancer risk.2. Identify the supplements that may

reduce oral cancer risk.3. Identify the supplement suggested

for cancer protection that does not have strong scientific support.

Author ProfileJeff Burgess, DDS, MSD, (Retired) Clinical Assistant Professor, Department of Oral Medicine, University of Washington School of Dental Medicine; (Retired) Attending in Pain Center, University of Washington Medical Center; (Retired) Private Practice in Hawaii and Washington; Director, Oral Care Research Associates. He can be reached at jeffreyaburgess@hotmail.com .

Author DisclosureJeff Burgess, DDS, MSD, has no potential conflicts of interest to disclose.

Publication date: July 2014 Expiration date: June 2017

This educational activity was developed by PennWell’s Dental Group with no commercial support.This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content.Requirements for Successful Completion: To obtain 1 CE credit for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%.CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products or services discussed in this educational activity. Heather can be reached at hhodges@pennwell.comEducational Disclaimer: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.Image Authenticity Statement: The images in this educational activity have not been altered.Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents the most current information available from evidence based dentistry. Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the data and information contained in reference section. The research data is extensive and provides direct benefit to the patient and improvements in oral health. Registration: The cost of this CE course is $20.00 for 1 CE credit. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

Supplement to PennWell Publications

PennWell designates this activity for 1 Continuing Educational Credit.

Dental Board of California: Provider 4527, course registration number 01-4527-14020“This course meets the Dental Board of California’s requirements for 1 unit of continuing education.”

The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2011) to (10/31/2015) Provider ID# 320452.

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Learning ObjectivesAt the conclusion of this educational activity participants will be able to: 1. Describe the foods that increase or decrease oral cancer

risk.2. Identify the supplements that may reduce oral cancer risk.3. Identify the supplement suggested for cancer protection

that does not have strong scientific support.

AbstractThe relationship between diet and oral cancer is complex and not fully understood at present. A number of foods and food products have been associated with the development of oral cancer and some foods, nutrients, and supplements have been linked to cancer pre-vention. This course briefly reviews some of the current nutrition science assessing relative risk and the prevention of oral cancer.

Oral cancer is widespread throughout the world with esti-mates of 400,000 cases occurring annually. The most common form of oral cancer is squamous cell carcinoma which can arise on virtually any intra-oral surface and accounts for about 3% of all cancers in the United States alone. Men tend to be at greater risk but the incidence varies by country and race. The five year survival rate is approximately 50%. About 85% of oral carcino-mas arise on the lips, tongue, oropharynx, and floor of the mouth but other tissues such as the attached gingiva and soft palate can be involved.

The relationship between oral cancer and diet is complex. Some specific dietary foods or ‘formulations’ appear to cause oral squamous cell carcinoma. For example, in India and Asia the chewing of areca nuts, betel nuts, paan and gutka has been significantly correlated with the development of oral squamous cell carcinoma.1 In addition, the odds of developing another oral cancer - nasopharyngeal cancer – appear to be increased by the consumption of canton-style salted fish, preserved vegetables and preserved/cured meat. In contrast, the consumption of fresh fruit, Canton-style herbal tea, and herbal slow-cooked soup is (in a dose-dependent relationship) associated with reduced risk.2

Although not a food, alcohol intake has also been shown to be related to the development of oral cancer, particularly when it is used in combination with smoking.3

Some foods appear to reduce the risk of oral cancer, including the development of oral cancer in people who use alcohol and smoke. Marshall and Boyle, in Cancer Causes Control, 1996, report that case-control evidence indicates that there may be a protective effect for some types of food.4 For example, vegetables appear to be protective. These include the alliums, carrots, green vegetables, cruciferous vegetables, and tomatoes. The benefit appears to be greatest when these foods are eaten raw.5,6

In a 2002 study published in Cancer, 106 Greek patients with confirmed oral carcinoma and an equal number of control sub-jects matched for age and gender and dietary information were assessed for ‘food frequency’. After adjustment for a number

of variables, including tobacco smoking and alcohol consump-tion, it was found that the consumption of cereals, fruits, dairy products, and lipids in the form of olive oil and the ingestion of micronutrients such as riboflavin, magnesium, and iron was inversely associated with the risk of oral carcinoma. Their study also found that eating meat products increased risk.7

Additional support for risk reduction from the intake of fruits and vegetables comes from a meta-analysis of sixteen studies (15 case-control studies and 1 cohort study meeting the inclusion criteria) taken from the medical literature published up to 2005.8 This systematic review suggests that daily fruit and vegetable consumption can reduce the risk of oral cancer by 49 and 50 percent respectively. But as the authors note, their conclusion is limited by study deficiencies such as population heterogeneity and design, subject recall and analysis of the data.

The literature with respect to nutrient supplementation (ver-sus food) and oral cancer is mixed. One of the nutrients that the epidemiologic data suggests may be helpful in reducing cancer risk is selenium. In a case-controlled study involving 379 cases and 514 controls, men with oral cancer were found to have lower nail selenium and zinc concentrations in nail clippings, but this was not the case for women. Smoking was associated with lower levels of both zinc and selenium.9 However, as the authors of this study point out, the reduction in risk from selenium supple-mentation may be confounded by the type of selenium supplied (salts or organic), the general nutrition status of individuals, their dilatory habits (e.g. smoking and alcohol), dosage considerations and other lifestyle factors. Other studies suggest that there may also be gender differences in terms of how the supplement is me-tabolized. To further dampen the excitement over the potential benefit of selenium in reducing cancer risk, a 2011 Cochrane Review indicates that there is little evidence supporting its use in reducing general cancer risk (the Cochrane Review, 2011 -Se-lenium for preventing cancer) (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3692366/).10

Other ‘antioxidants’ that have been reported as helpful in preventing oral cancer include Vitamin E ([alpha]-tocopherol NOT [Upsillion]-tocopherol, and the carotenoids ([beta]-car-otene, [alpha]-carotene, cryptoxanthine, lutein, and lycopene), particularly [beta]-carotene).11 It is hypothesized that these sub-stances protect cell DNA from the effects of oxidative enzymes. Supplementation by antioxidants in an attempt to reduce cancer risk has been assessed in multiple animal and human studies.12-15 The accumulated evidence suggests that there may be a risk lowering effect of a variety of antioxidant substances that could potentially be incorporated as supplements.16

In an interesting study assessing the antioxidant enzymatic activity in saliva of patients with oral cancer and odontogenic cysts compared with healthy controls, subjects with oral cancer were found to exhibit lower total antioxidant capacity and sali-vary peroxidise and superoxide dismutase activity in their saliva than controls. Based on this evidence, the authors conclude that “the decrease in concentrations of major antioxidants in the

RDH | July 2014 rdhmag.com | 61

saliva of patients with cysts may increase the risk of neoplastic transformation especially in advanced age”.17

In another study of nutrient-based dietary patterns and the risk of head and neck cancer, pooled data from five case controlled studies involving over 2452 cases and 5013 controls revealed that the ‘antioxidant vitamins and fiber’ pattern of dietary intake was inversely related to oral and pharyngeal cancer (OR = 0.57, 95% CI 0.43-0.76 for the highest versus the lowest score quintile). In addition, the intake of dietary ‘fats’ was inversely associated with the development of oral and pharyngeal cancer (OR = 0.78, 95% CI 0.63-0.97).18 But even though the analysis of this compiled data and the results of additional in vivo and in vitro studies19 are encouraging with respect to risk prevention and help to clarify the possible contribution of antioxidants and dietary polyphenols to oral cancer risk, it should be appreciated that recent large scale randomized clinical trials have been inconsistent with respect to clinical outcomes for antioxidants and their cancer preventing capibilities.20

Nevertheless, given what is currently known from the nutri-tional science, nutrients/foods that might be recommended to patients for reducing cancer risk include:1. Potatoes, carrots, cantaloupe, squash, apricots, pumpkin,

mangos, some green leafy vegetables such as collard greens, spinach, and kale (which contain beta-carotene). However in men who smoke the risk might increase rather than decrease when green leafy vegetables are eaten.21

2. Liver, sweet potatoes, carrots, milk, egg yolks, and mozzarella cheese (which contain Vitamin A)

3. Vegetables, cereals, poultry, and fish (which contain Vitamin C)

4. All categories of fruits, non-citrus fruits, and citrus fruits21 5. Green tea and coffee 22,23

Foods that are known to increase cancer risk include:1. Areca nuts, betel nuts, paan, gutka2. Animal fat3. Canton-style salted fish4. Canton-style preserved vegetables and preserved/cured meat

The intake of alcohol also increases oral cancer risk, especially in woman with low folate intake.24

Bibliography1. Warnakulasuriya S, Trivedy C, Peters T. Areca nut use: an independent

risk factor for oral cancer BMJ. 2002 April 6; 324(7341): 799–800. 2. Jia WH, Luo XY, Feng BJ, Ruan HL, Bei JX, Liu WS, Qin HD, Feng

QS, Chen LZ, Yao SY, Zeng YXTraditional Cantonese diet and nasopharyngeal carcinoma risk: a large-scale case-control study in Guangdong, China. BMC Cancer. 2010 Aug 20;10:446.

3. http://oralcancerfoundation.org/facts/alcohol_tobacco.htm; accessed 4.22.14.

4. Marshall JR, Boyle P. Nutrition and oral cancer. Cancer Causes Control 1996 Jan; 7(1):101-11.

5. Latino-Martel P, Druesne-Pecollo N, Dumond A. Nutritional factors and oral cancers. Rev Stomatol Chir Maxillofac. 2011, Jun;112(3):155-159.

6. Steinmetz KA, Potter JD. Vegetables, fruit and cancer prevention: a

review. J Am Diet Assoc. 1996, Oct; 96(10):1027-1039. 7. Petridou E, Zavras Al, et al, The role of diet and specific micronutrients in

the etiology of oral carcinoma. Cancer. 2002 Jun 1; 94(11):2981-8 8. Pavia M, Pileggi C, et al. Association between fruit and vegetable

consumption and oral cancer: a meta-analysis of observational studies. American J of Clin Nutrition, May; 83(5):1126-1134, 2006.

9. Rogers M, et al. A case-control study of oral cancer and pre-diagnostic concentrations of selenium and zinc in nail tissue. Int J of Cancer. 1991, 48(2):182-188.

10. http://www.cochranejournalclub.com/selenium-preventing-cancer-clinical/pdf/CD005195.pdf. Assessed 4/22/14.

11. ht t p : / / f i n d a r t i c l e s . co m / p / a r t i c l e s / m i _ m 0 8 8 7 / i s _ n 4 _ v 1 2 /ai_13895943/; assessed 4/22/14.

12. Dhanarasu S, Selvam M, et al. Terminalia Arjuna. (Roxb.) modulates circulatory antioxidants on 7,12-dimethylbenz(a)anthracene-induced hamster buccal pouch carcinogenesis. Oman Med J. 2010 Oct; 25(4):276-81.

13. Ljju VB, Jeena K, Kuttan R. An evaluation of antioxidant, anti-inflammatory, and antinociceptive activities of essential oil from Curcuma longa. L. Indian J Pharmacol. 2011 Sep; 43(5):526-31.

14. Korde SD, Basak A, et al. Enhanced nitrosative and oxidative stress with decreased total antioxidant capacity in patients with oral precancer and oral squamous cell carcinoma. Oncology, 2011; 80(5-6):382-9.

15. Suresh K, Manoharan S, et al. Chemopreventive and antioxidant efficacy of (6)-paradol in 7,12-demethylbenz(a)anthracene induced hamster buccal pouch carcinogenesis. Pharmacol Rep. 2010 Nov-Dec; 62(6):1178-85.

16. Garewal H. Antioxidants in oral cancer prevention. Am J Clin Nutr, Dec 1995; 62(6):1410S-1416S.

17. Giebultowicz J, Wroczynski P, Samolczk-Wanyura D. Comparison of antioxicant enzymes activity and the concentration of uric acid in the saliva of patients with oral cavity cancer, odontogenic cysts and healthy subjects. J Oral Pathol Med. 2011; April 18 [Epub ahead of print].

18. Edefonti V, Hashibe M, et al. Nutrient-based dietary patters and the risk of head and neck cancer: a pooled analysis in the internation head and neck cancer epidemiology consortium. Ann Oncol. 2011, Nov 28 [Epub ahead of print].

19. Yijian Ding. Protection of Dietary Polyphenols against Oral Cancer Nutrients. Jun 2013; 5(6): 2173–2191.

20. http://www.cancer.gov/cancertopics/factsheet/prevention/antioxidants; assessed 4/22/14.

21. Maserejian N, et al American Journal of Epidemiology in 2006, Am J Epidemiol, 2006. 164:556-566

22. Yu, Xiaofeng, et al., Coffee consumption and risk of cancers: a meta-analysis of cohort studies. BMC Cancer. 2011; 11: 96.

23. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3047460/. Accessed 4/22/14

24. Shanmugham JR. Alcohol-folate interactions in women’s oral cancer risk: A prospective cohort study; Cancer Epidemiol Biomarkers Prev. Oct 2010; 19(10): 2516–2524.

Author profileJeff Burgess, DDS, MSD, (Retired) Clinical Assistant Professor, Department of Oral Medicine, University of Washington School of Dental Medicine; (Retired) Attending in Pain Center, Univer-sity of Washington Medical Center; (Retired) Private Practice in Hawaii and Washington; Director, Oral Care Research Associ-ates. He can be reached at jeffreyaburgess@hotmail.com .

Author DisclosureJeff Burgess, DDS, MSD, has no potential conflicts of interest to disclose.

62 | rdhmag.com RDH | July 2014

Questions

Online CompletionUse this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

1. It is estimated that the total number of oral cancer cases worldwide is:a. 100,000b. 200,000c. 400,000d. 1,000,000

2. The five year survival rate for oral cancer is approximately:a. 50%b. 10%c. 75%d. 85%

3. Which of the following has been associated with the development of oral cancer?a. Betel nutsb. Paan c. Areca nutsd. All of the above

4. Which of the following dietary products has been associated with a reduced risk of nasopharyngeal cancer?a. Fresh fruitb. Canton-style herbal teac. Herbal slow-cooked soupd. All of the above

5. In an individual who smokes and drinks, which is the best way to consume vegetables to reduce cancer risk?a. Friedb. Rawc. Cooked over steamd. Boiled

6. Which of the following statements is inac-curate, based on a Greek study published in Cancer, 2002?a. Ingestion of meat products reduces the risk of oral

cancer.b. The consumption of cereals, fruits, dairy products,

and olive oil is inversely associated with the risk of oral carcinoma.

c. Ingestion of riboflavin, magnesium, and iron micronu-trients is inversely associated with oral cancer risk.

d. There is support for a relationship between diet and oral cancer risk.

7. Which of the following micro-nutrients is not thought to be helpful in reducing oral cancer risk?a. Vitamin E [alpha]-tocopherolb. Seleniumc. Carotenoids [beta]-carotene d. Flavonoids

8. In an interesting study looking at antioxi-dant enzymatic activity in saliva of patients with oral cancer and odontogenic cysts it was found that:a. Subjects with oral cancer had lower total antioxidant

capacity than controls.b. Subjects with oral cancer had lower levels of salivary

peroxidises and superoxide dismutase than controls.c. Both a and bd. Neither a or b

9. Which of the following food products contain beta carotene?a. Carrotsb. Mangosc. Squashd. All of the above

10. Which of the following beverages has not been associated with a reduced risk of oral cancer?a. Green teab. Coffeec. Canton-style herbal tead. Alcohol

Notes

Customer Service 216.398.7822

Educational Objectives1. Describe the foods that increase or decrease oral cancer risk.

2. Identify the supplements that may reduce oral cancer risk.

3. Identify the supplement suggested for cancer protection that does not have strong scientific support.

Course Evaluation1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No

Objective #2: Yes No

Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.

2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0

3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0

4. How would you rate the objectives and educational methods? 5 4 3 2 1 0

5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0

6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0

7. Was the overall administration of the course effective? 5 4 3 2 1 0

8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0

9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0

10. Do you feel that the references were adequate? Yes No

11. Would you participate in a similar program on a different topic? Yes No

12. If any of the continuing education questions were unclear or ambiguous, please list them. ___________________________________________________________________

13. Was there any subject matter you found confusing? Please describe. ___________________________________________________________________ ___________________________________________________________________

14. How long did it take you to complete this course? ___________________________________________________________________ ___________________________________________________________________

15. What additional continuing dental education topics would you like to see? ___________________________________________________________________ ___________________________________________________________________

ANSWER SHEET

Diet and Oral Cancer

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Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 1 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822

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INSTRUCTIONSAll questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be mailed within two weeks after taking an examination.

COURSE CREDITS/COSTAll participants scoring at least 70% on the examination will receive a verification form verifying 1 CE credit. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is 4527. The cost for courses ranges from $20.00 to $110.00.

PROVIDER INFORMATIONPennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

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The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2011) to (10/31/2015) Provider ID# 320452.

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Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.

CANCELLATION/REFUND POLICYAny participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

IMAGE AUTHENTICITYThe images provided and included in this course have not been altered.

© 2014 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell DIET714RDH