Mouth Cancer - What you need to know

April is Oral Cancer Awareness Month.  

What should we be aware of and why is it important?

The bad news:

Oral cancer is defined as cancer of the lip, mouth or tongue. It can be a devastating disease. In India it is one of the most common forms of cancer, accounting for between 30% and 40% of all malignancies (higher than in other parts of the world). Although the prognosis can be good if spotted early, the majority of those with the disease are diagnosed too late. This type of cancer is very malignant, meaning that it can spread quickly if not treated early. 

People are dying because of lack of awareness.

The good news:

Many types of mouth cancer are preventable by avoiding the known risk factors. It is also possible to spot signs of early signs of mouth cancer or conditions that can lead to cancer by regular, thorough mouth examinations. If people are aware of the possible signs and symptoms they can be alerted to see a dentist or doctor as soon as they spot these. The earlier a lesion is diagnosed and treated the better the outcome. 

Risk factors and prevention

Tobacco use has been shown to be the biggest risk factor for developing mouth cancer. Tobacco contains carcinogens (substances directly involved in causing cancer) and causes approximately 85% of all cancers of the head and neck. Tobacco is a risk factor whether it it smoked or chewed. One of the reasons for the higher incidence of mouth cancer in South Asia is the widespread use of tobacco in paan, gutkha or betel quid. These are typically kept in the cheek and chewed or sucked for some time. 

Other risk factors include:

• Heavy alcohol consumption (particulary when combined with tobacco use)
• UV radiation from sun exposure can cause lip cancer (as well as skin cancer)
• Infection with Human Papilloma Virus (HPV)
• Chronic trauma from a sharp tooth or ill-fitting dentures
• Poor diet, lacking in fruit and vegetables
• Genetic factors

Early detection

Oral cancer can start in the floor of the mouth, gums, lips, inside the cheek or on the tongue or palate. Some cancers may start as "pre-malignant lesions" - these are areas which have a risk of developing into cancer and so need to be monitored.

The most common early signs are:

• An ulcer with no obvious cause which does not heal after 2 weeks
• A white, red or speckled patch which cannot be rubbed off                                                                                                                                                 These are usually not painful in the early stages.

                (Photographs courtesy of http://www.oralcancerawareness.org)

Other signs and symptoms to look out for:

• Unexplained pain or numbness in the mouth or ear area
• Lump in the neck 
• Difficulty swallowing or opening the mouth

If you have any of these, it doesn't necessarily mean you have cancer. It just means that you should get checked by your dentist or doctor. They will either be able to reassure you, or arrange for further tests if necessary.

Regular check-ups with your dentist will enable them to examine your whole mouth (not just your teeth). No one wishes or expects to get cancer but if early signs are seen, treatment can be far easier and more successful than if cancer is diagnosed at a later stage.

Overcoming Dental Anxiety - Part 4

In this blog so far, we have discussed causes of dental fear and anxiety and ways to overcome them. 

In this concluding section we will look at some more issues, in particular the importance of good pain control and techniques for relaxation.

Fear of being awake for treatment

One major difference between dentistry and other medical specialties is that, most of the time, patients remain awake for treatment. Many patients with a dental phobia say that they would like to be "knocked out" (have a general anaesthetic) for treatment but there are reasons why a general anaesthetic (GA) is not used routinely, but only as a last resort, in dentistry. There are risks associated with having a GA and it is required that general anaesthetics are only carried out in a fully equipped hospital. Weighing the risks against the benefits, GA is generally only justified for complex oral surgery or for urgent treatment when other methods, eg. psychological techniques and sedation, have been tried unsuccessfully. In addition, having treatment while asleep will not help a person with dental phobia overcome their fears and it will not be possible to keep having treatment under GA in the future. It is much better to find a good, sympathetic dentist who will work with you as we have discussed in part 2 of this blog.

Fear of "the drill"

For many people, even the sound of the dental handpiece (or drill) can make them very anxious. This may be due to a previous bad experience where the tooth was not sufficiently numb and/or the dentist did not stop treatment when they felt pain. 

When a tooth is properly numb, the only sensations that should be felt are vibration and slight pressure (see more about this in under subheading "fear of pain"). However, for some, the vibration itself can be uncomfortable. If this is the case, using an electric tooth brush at home may be help you get used to the vibration sensation. 

Many people do not like the sound of "the drill". Music can be helpful to blend out unpleasant sounds. Some dentists have music in the treatment room, or you could bring your own mobile device with your favourite songs or music for relaxation on. Of course, you would need to turn the music off when you need to speak to the dentist.

Other distractions, such as watching a video, either on a screen above the dental chair or by wearing virtual reality goggles, may also help. Sometimes it is helpful if your dentist tells you that they will need to use the handpiece for 5 or 10 seconds at time and even counts this out loud. Don't forget, you can let your dentist know that you need to take a break by raising your hand. This is called the "stop signal" which we discussed in part 3 of this blog

Fear of Pain

If you have had a past experience of painful treatment at the dentist this will have most likely have led to fear and anxiety. 

The reason for pain could have been:

• Not having local anaesthetic (LA) to numb the tooth when it was required.
• The dentist starting treatment without allowing sufficient time for the local anaesthetic to work - this can take between 5 and 15 minutes, depending on the tooth and procedure.
• Infection in the tooth or surrounding area may prevent the LA working properly. This can sometimes be a problem during root canal treatment and antibiotics or a sedative dressing placed in the tooth between visits may be required.
• Painful injection (see next paragraph).
• The dentist not stopping when you felt pain to make you comfortable or give more local anaesthetic.

All of these problems can be overcome with a combination of good communication and using the right techniques. Don't be afraid to tell your dentist if you experience pain so that they can do something about it.

Fear of injections

Maybe when local anaesthetic injections were mentioned in the last paragraph, you thought "but that is my biggest fear!" This is quite common, to the extent that some people would rather suffer pain during treatment that have the numbing injection. Generally, the thought of having an injection is much worse than the reality and there are ways that your dentist can help you:

• A good relationship with a dentist you can trust goes a long way in relieving anxiety.
• A topical gel or spray can be used to numb the gum first, this takes a couple of minutes to work.
• Injection should be slow and gentle - fast injection can cause pain.
• Distraction - your dentist may talk to you or you may listen to music or watch a video.
• Relaxation techniques (discussed below).
• Try to think about the benefits of your tooth being numb so that you will not have pain during treatment.

Fear of choking or gagging

Some people have a strong gag reflex or have a fear of choking while at the dentist. There is a physical aspect to this but anxiety will also cause these problems to be worse. The following solutions may help:

• Discuss the problem with your dentist so that they can find ways to help you.
• Slow breathing through your nose. For those who have a problem with this, a nasal spray used beforehand may help.
• Your dentist could use a numbing throat spray to make the area less sensitive. Some people also find rinsing with salty water or putting salt on the tip of their tongue has a similar effect.
• Desensitization - you could ask your dentist if you can borrow a mouth mirror to practice placing it in your mouth at home.
• Distraction or humming to yourself.
• Relaxation techniques (discussed below).
• Inhalation sedation using nitrous oxide mixed with oxygen (discussed below) is also known to reduce the gag reflex as well as anxiety.

Relaxation Techniques

Relaxation is the opposite of anxiety and it is impossible to be relaxed and anxious at the same time. There are various relaxation techniques that you can try to see which works best for you. All of these need to be practiced regularly at home. They will not work if you start while in the dental chair.

Click on each for a link with more details:

• Deep breathing techniques
• Aromatherapy
• Music which aids relaxation
• Yoga and meditation
• Progressive muscle relaxation
• Self hypnosis and visualisation

Sedation

So what if you have tried the techniques suggested and you still can't cope with dental treatment? 

This is where conscious sedation comes in. Sedation is used to reduce anxiety and aid relaxation, making dental visits more comfortable. You will still be awake but less anxious. You can discuss the options with your dentist. If they do not offer the type of sedation which is right for you, they may be able to refer you to someone who does.

There 3 types of sedation commonly used in dentistry:

• Inhalation sedation - a mixture of nitrous oxide (laughing gas) and oxygen is inhaled through a rubber cup which fits comfortably over the nose throughout treatment. The sedation reduces anxiety so that you feel happy and relaxed. This is the safest and gentlest form of sedation with few side effects and fast recovery time. It can be used for children and adults. Inhalation sedation is available at Smile Station in Bangalore. You can contact the practice for more details.

• Oral sedation -  a medication (usually a benzodiazepine) prescribed to be taken in the hours before a dental appointment, or sometimes the night before, which has sedative and anti-anxiety effects. These should only be taken on the advice of your physician and/or dentist as they have side effects and may interact with other medication. You should not drive or operate machinery after taking oral sedation. 

• Intravenous (IV) sedation - a sedative drug is administered into the bloodstream through a vein. This induces a deeper state of relaxation but you will still be awake. It may give either partial or full memory loss during the time of sedation. IV sedation is only recommended for adults and impairs ability to drive or operate machinery.

Remember, sedation is never a substitute for a good, caring dentist who will work with you to overcome your fears.


Finally, here is a testimonial from Chelsea - a patient at Smile Station who has been able to overcome her anxiety:

"Smile Station, a place I never thought would actually be pleasant to go to. Simply because it was a dentist's clinic. but my experience here made me change my entire opinion and made me feel extremely comfortable. A root canal from what I had heard was supposed to be the most painful thing, but Dr. Gurudev being so experienced made it feel like a cake walk. He was extremely gentle and helped me get over my fear of the dentist. The facilities are extremely good too! I am so happy I chose to come to Smile Station and I would recommend this clinic to anyone!''

If you have any comments on this blog, or would like to see any other topics covered, please post a message below.

Overcoming Dental Anxiety - Part 3

As we discussed in the first part of this blog, dental anxiety is common. However, individuals may face different issues depending on their personalities and past experiences.

In the following 2 sections we will cover some specific fears and anxieties and look at ways of overcoming them.

Loss of Control

A big issue for many people is the feeling of loss of control when visiting the dentist. You may feel like you do not know what is going on in your mouth or that you are not able to have a say in what the dentist does.

You may have had bad experiences in the past with a dentist who did not explain what they were doing or why. This may have given you the feeling that dentistry is something that "is done to you" rather than you being a partner in your dental care.  As discussed in the previous post - finding a good dentist who you can communicate well with is vital in overcoming anxiety. A good dentist will explain treatment options, along with risks and benefits in a way that you can understand. You may need to take some time to consider your options before agreeing to treatment. 

Dentists are required to obtain "informed consent" before treatment. Sometimes you may be asked to sign a consent form. Only sign this if you feel you have enough information to agree to treatment - if not then ask questions. A good question to ask your dentist is what would they choose if it were their tooth or mouth. You should also know the likely consequences if you choose to have no treatment. Remember, you should be in control and always have a choice in your treatment.

Similarly, a good dentist will explain what is involved in your treatment from your point of view, what sensations you are likely to feel and how to let them know if you want them to stop or take a break. Some dentists may ask you to raise your hand if you have any discomfort or need a break. This enables you to give a stop signal to your dentist when you are not able to talk easily without suddenly moving your head. Another option is to agree to take a break after an agreed number of minutes, this can be useful if you are afraid to interrupt the dentist while they are working. However, if you have any significant discomfort, don't be afraid to raise your hand to let the dentist know. If you have a good relationship with a dentist you can trust they will stop and try to make you comfortable. 

Often, it is helpful if your dentist not only explains the procedure but also demonstrates any tools or materials before using them. This technique, called tell-show-do, is often used for children but can also be very beneficial for adults who are anxious. For example, you can feel the dental instrument on the back of your hand or your finger nail before it is used in your mouth so that you know what it feels like.

As we discussed in the previous section of this blog, it is best to overcome anxieties one step at a time. You should become comfortable with having a check-up, or cleaning before moving onto longer or more complex procedures. Relaxation is important in this process. In the next section, we will also discuss some relaxation techniques.

The Dental Chair

For some people with a dental phobia just the thought of lying in the dental chair can be terrifying. Lying down can make you feel exposed or vulnerable. It is often possible to do a check up with the dental chair upright, or even in a normal chair. For treatment, you can ask your dentist if is possible to leave the chair in a more upright or semi-reclined position. For some procedures, especially if working on the back or top teeth, the dentist will need the chair to be more reclined but you can ask for this to be done gradually, so that you can get used to it. If you don't like the feeling of being tipped back then you can ask for the chair to be put into the correct position before you sit or lie back.

Fear of "the diagnosis" or embarrassment

If you have a dental phobia you will probably have put off visiting the dentist even when you have pain or know that they need urgent treatment. This can lead to embarrassment and the feeling that you have the worst teeth the dentist has ever seen. You may also fear being "told off" or receiving a lecture from the dentist. You may also fear that you need a lot of extensive treatment.

Dentists will have seen a wide variety of people and their mouths so it is unlikely that anything in your mouth shock them. These days, most dentists realise that scolding or lecturing their patients is counter-productive. A sympathetic dentist will understand how difficult it has been for you to visit a dentist after a long time and will want to work with you to overcome your fears and improve your oral health. 

Also, dentists should maintain confidentiality and not discuss your diagnosis or treatment in front of other patients or members of the public. You can ask to discuss your treatment in a private setting and have the door closed during treatment if this is an issue for you.


Here is the experience of one patient, Garima, from Smile Station, Bangalore who has been able to overcome her dental phobia:

"I had dentist phobia and there was so much of work to be done on my teeth, but I was always afraid of visiting dentist, in fact I had never visited one. I randomly walked into Smile station for a check up, and Dr Guru did not make me nervous. He would be so patient throughout the treatment which is commendable, given the fact that he is always busy. But what I experienced was he would never ignore or take any patient lightly. Another very good thing is he will exactly tell what needs to be done, gives various options and explains pros and cons of each treatment, so that a person is involved and knows what is going on. I feel that every service / treatment at Smile Station has a personal touch in it. I have now shifted to London, but make sure that on my way back India, I see Dr. Guru as well as get the check up done. I just feel that I / my teeth :-) are in safe hands."

In the next section we will look at more factors which can cause anxiety and techniques which can help. 

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