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Oral Cancer and Periodontal Disease

Salivary PCR testing...why every person with a mouth should be tested.

by Nick Ritzema

April is designated as Oral Cancer Awareness month, which is a great reminder of the importance of oral cancer screenings…not just each Spring, but throughout the year.  Whether you personally complete an oral cancer exam on every patient that sits in your chair, or you rely on your amazing and astute dental hygienists to complete an oral cancer exam, finding a concerning result can be a terrifying ordeal for both patient and provider. When a biopsy comes back positive that patient’s life is forever changed. As healthcare providers, we often second guess every interaction we have had with that patient; “Did I do everything I could have done?” “Could I have found this earlier if I had spent an extra moment looking?” “What can I do to prevent this from happening to another one of my patients?”  

Often, these are questions that we internalize as healthcare providers that genuinely care.  

No one ever told me in dental school that I would make money performing oral cancer screenings on my patients. If they had, I would have questioned their motives, morality, sanity, or all the above. As dental providers, we perform oral cancer screening not only because we are expected to but more importantly because it is the right thing to do. We care about the people, not just the smiles, that sit in our chairs.  

The question that I would encourage you to ask yourself is this: “If I can be profitable PREVENTING cancer, why would I not want to save more lives even before a biopsy referral is needed?” 

One of the most interesting cancer statistics to me is that one in two Americans will develop cancer within their lifetime. Shockingly, the incidence of any form of periodontal disease is also one in two in the United States. Half of all Americans will have some form of gum disease and half of all Americans will be diagnosed with cancer. What if I told you these statistics are more than likely discussing the same half of our population?  

More research is connecting periodontal pathogens to systemic health concerns. The primary focus of much of this research has been the connection to arterial and cardiovascular health. As oral healthcare providers, we cannot stop with only the cardiovascular connection. Twenty years ago, doctors Beck and Offenbacher published the notion of systemic periodontitis where, “Periodontal disease must be thought of as a disease process that is an exposure for a systemic disease or condition rather than the outcome itself.” Now here we are, in 2022, and dental practices are still scraping plaque, scaling tarter, and “cleaning” teeth. We, as an entire healthcare profession, need to stand up for the lives behind all those smiles that we help create.  

Today, a fraction of patients in less than half of all American dental practices have a completed periodontal chart. The incompletion of these charts is not the only problem. The LARGEST problem is that measuring periodontal pocketing, bleeding on probing, attachment loss, bone loss, furcation involvement, and everything else that periodontal charts measure is not true prevention. Once inflammation exists, systemic disease is present. It is time for dentistry to take true ownership of OUR piece of systemic inflammation. This means setting the standard of care for periodontal pathogen testing in saliva for every individual that walks into our practices and sits in our chairs. This means treating the infection before there is measurable clinical evidence on a periodontal chart. This means SAVING our patients’ lives 10, 20, 30 or more years before they could be at risk….and putting the HEALTH back in healthcare. 

In much of oral and systemic health research, key pathogens that get a lot of attention are Aggregatibacter actinomycetemcomitans (Aa) and Porphyromonas gingivalis (Pg). These are considered red-complex pathogens and are among the highest risk pathogens for systemic chronic inflammatory diseases. Newer research, however, is showing Fusobacterium nucleatum (Fn), a pathogen which has previously been considered to have a lower systemic risk, as having strong correlation to the development of various forms of cancer. Fn produces specific exotoxins and enzymes that not only promote the systemic migration of more “high-risk” periodontal pathogens, but they also induce a specific type of inflammatory response that activates cancer promoting genes. In addition, researchers have shown that the presence of Fn can block apoptosis in cancer cells and facilitate tumorigenesis by promoting cancer cell proliferation and tumor growth. Head and neck cancers, colorectal cancer, pancreatic cancer, breast cancer, and all forms of cancer morbidity have been linked to systemic migration of these periodontal pathogens. 

There is no longer a viable excuse for incomplete periodontal diagnostics. As of April 2022, 850 million COVID-19 tests had been completed in the United States since the start of the pandemic. This is nearly three times the actual United States population! Salivary PCR testing for high-risk periodontal pathogens has been available for over a decade, yet it is one of the least implemented tools in preventative medicine. These tests are inexpensive when compared to the cost of managing chronic diseases linked to periodontal pathogens. These tests are widely disseminated and available to all dental and medical practices in the United States. There are various opinions on which tests are best according to cost, ease of use, amount and type of bacterial data acquired, etc. One thing is resoundingly clear: every person with a mouth should be tested. This should not be limited to adults; true prevention starts with our children! 

Periodontal treatment protocols can vary from group to group, practice to practice, and even dentist to dental hygienist. No matter what your treatment philosophy may be, saliva testing should be your new standard of care for screening, diagnosis, and evaluation of treatment outcomes. This especially means that follow-up testing after any form of treatment is vitally important. A clear post-treatment test reassures you that you have done your part as the provider for that patient’s health. A post-treatment test that is not clear of pathogens allows for continuation of the conversation of additional therapeutic treatment options and holds patients accountable for their share in their treatment.

If you or your dental hygiene team would like to evaluate the various salivary diagnostic companies, need updates on the most effective, and most profitable treatment protocols, or want to boost all around case acceptance through improved knowledge and confidence in explaining oral systemic health, visit The American Academy for Oral & Systemic Health (www.aaosh.org).  Also consider registering for the 2022 AAOSH conference – Collaboration Cures in Phoenix, AZ, September 15th through the 18th, and help bring HEALTH back to healthcare. 

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