Increasing opportunistic oral cancer screening examinations: findings from focus groups with general dentists in Puerto Rico.

This study aims to identify educational and training modalities that dentists in Puerto Rico (PR) believe will increase the quality and quantity of opportunistic oral cancer screening examinations (OCS) in dental offices on the island. The study was conducted in three phases: a systematic search of relevant literature, an expert review and consensus panel, and focus groups (FG) involving PR general dentists. To increase OCS by dentists in PR, the FG participants proposed a small group, hands-on OCS training, an integrated oral cancer course, and readily available videos, photographs, and computer simulations to further demonstrate OCS performance and facilitate differential diagnosis. OCS training requirements for licensure and re-licensure, improving OCS dentist-patient communication skills, and establishment of an oral lesion referral center were also viewed favorably. In conclusion, general dentists in our FGs believed the quality and quantity of OCS in Puerto Rico can be increased through the application of specific continuing education and training modalities.

Cytokines and tumor metastasis gene variants in oral cancer and precancer in Puerto Rico.

OBJECTIVES: A cross-sectional epidemiological study explored genetic susceptibility to oral precancer and cancer in Puerto Rico (PR). MATERIALS AND METHODS: Three hundred three individuals with a benign oral condition, oral precancer (oral epithelial hyperplasia/hyperkeratosis, oral epithelial dysplasia), or oral squamous cell carcinoma (SCCA) were identified via PR pathology laboratories. A standardized, structured questionnaire obtained information on epidemiological variables; buccal cells were collected for genetic analysis. Genotyping was performed using Taqman® assays. Allelic frequencies of single nucleotide polymorphisms (SNPs) were evaluated in cytokine genes and genes influencing tumor metastasis. Risk estimates for a diagnosis of oral precancer or SCCA while having a variant allele were generated using logistic regression. Adjusted models controlled for age, gender, ancestry, education, smoking and alcohol consumption. RESULTS: Relative to persons with a benign oral lesion, individuals with homozygous recessive allelic variants of tumor necrosis factor (TNF-α) -238 A/G SNP had a reduced odds of having an oral precancer (ORadjusted = 0.15; 95% CI 0.03-0.70). The transforming growth factor beta-1 (TGFß-1 -509 C/T) polymorphism was inversely associated with having an oral SCCA among persons homozygous for the recessive variant (ORcrude = 0.27; 95% CI 0.09-0.79). The matrix metalloproteinase gene (MMP-1) variant, rs5854, was associated with oral SCCA; participants with even one variant allele were more likely to have oral SCCA (ORadjusted = 2.62, 95% CI 1.05-6.53) compared to people with ancestral alleles. CONCLUSION: Our exploratory analyses suggest that genetic alterations in immune system genes and genes with metastatic potential are associated with oral precancer and SCCA risk in PR.

A preliminary study on the relationships between global health/quality of life and specific head and neck cancer quality of life domains in Puerto Rico.

PURPOSE: Health-related quality of life (HRQOL) is an important treatment outcome for head and neck cancer (HNC) patients. By ascertaining the most important HNC HRQOL issues, research and practice can be directed toward enhancing patient QOL. MATERIALS AND METHODS: A cross-sectional study of 46 ENT clinic HNC patients in Puerto Rico (PR) was completed. The European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 (general QOL), and the QLQ-H&N35 (HNC QOL) instruments were administered. Correlations and multivariable regressions were separately conducted for QLQ-H&N35 variables on the three QLQ-C30 outcome variables: overall health, overall QOL, and the global health/QOL domain. RESULTS: Correlation findings included statistically significant negative correlations between the three QLQ-C30 outcome variables and the QLQ-H&N35 variables pain, swallowing, social eating, social contact, and sexuality. Multivariable linear regression identified statistically significant inverse indicators of the outcomes: (1) "lessening of sexuality" with "overall health" (p= 0.02), (2) "problem with social eating" (p= 0.023), "taking pain killers" (p= 0.025), and "problem with social contact" (p= 0.035) with "overall QOL," and (3) "problems with social eating" (p < 0.009) and "taking pain killers" (p= 0.016) with the "global health/QOL" domain. CONCLUSIONS: We conclude that problems with pain, social eating, social interactions, and loss of sexuality are critical indicators of degraded HRQOL in HNC patients living in Puerto Rico. Our results add to the overall knowledge base regarding QOL among HNC patients. The promise of improved QOL for the HNC patient is attainable through additional research in conjunction with advances in clinical treatments and patient management protocols.

Self-reported ethnicity and genetic ancestry in relation to oral cancer and pre-cancer in Puerto Rico.

BACKGROUND: Hispanics are known to be an extremely diverse and genetically admixed ethnic group. The lack of methodologies to control for ethnicity and the unknown admixture in complex study populations of Hispanics has left a gap in understanding certain cancer disparity issues. Incidence rates for oral and pharyngeal cancer (OPC) in Puerto Rico are among the highest in the Western Hemisphere. We conducted an epidemiological study to examine risk and protective factors, in addition to possible genetic susceptibility components, for oral cancer and precancer in Puerto Rico. METHODOLOGY/PRINCIPAL FINDINGS: We recruited 310 Puerto Rico residents who had been diagnosed with either an incident oral squamous cell carcinoma, oral precancer, or benign oral condition. Participants completed an in-person interview and contributed buccal cells for DNA extraction. ABI Biosystem Taqman™ primer sets were used for genotyping 12 ancestry informative markers (AIMs). Ancestral group estimates were generated using maximum likelihood estimation software (LEADMIX), and additional principal component analysis was carried out to detect population substructures. We used unconditional logistic regression to assess the contribution of ancestry to the risk of being diagnosed with either an oral cancer or precancer while controlling for other potential confounders. The maximum likelihood estimates showed that study participants had a group average ancestry contribution of 69.9% European, 24.5% African, and 5.7% detectable Native American. The African and Indigenous American group estimates were significantly higher than anticipated. Neither self-identified ethnicity nor ancestry markers showed any significant associations with oral cancer/precancer risk in our study. CONCLUSIONS/SIGNIFICANCE: The application of ancestry informative markers (AIMs), specifically designed for Hispanics, suggests no hidden population substructure is present based on our sampling and provides a viable approach for the evaluation and control of ancestry in future studies involving Hispanic populations.

Smoking and drinking in relation to oral potentially malignant disorders in Puerto Rico: a case-control study.

BACKGROUND: Oral cancer incidence is high on the Island of Puerto Rico (PR), particularly among males. As part of a larger study conducted in PR, we evaluated smoking and drinking as risk factors for oral potentially malignant disorders (OPMDs). METHODS: Persons diagnosed with either an OPMD (n = 86) [oral epithelial dysplasia (OED), oral hyperkeratosis/epithelial hyperplasia without OED] or a benign oral tissue condition (n = 155) were identified through PR pathology laboratories. Subjects were interviewed using a standardized, structured questionnaire that obtained information, including detailed histories of smoking and drinking. Odds ratios (ORs) for smoking and drinking in relation to having an OPMD, relative to persons with a benign oral tissue condition, were obtained using logistic regression and adjusted for age, gender, education, fruit/vegetable intake and smoking or drinking. RESULTS: For persons with an OPMD and relative to individuals with a benign oral tissue condition, the adjusted OR for current smoking was 4.32 (95% CI: 1.99-9.38), while for former smokers, the ORadj was 1.47 (95% CI: 0.67-3.21), each ORadj relative to never smokers. With regard to drinking, no adjusted ORs approached statistical significance, and few point estimates exceeded 1.0, whether consumption was defined in terms of ever, current, level (drinks/week), or beverage type. CONCLUSIONS: In this study, conducted in Puerto Rico, current smoking was a substantial risk factor for OPMDs while former smokers had a considerably reduced risk compared to current smokers. There was little evidence suggesting that alcohol consumption was positively associated with OPMD risk.

Perspectives of San Juan healthcare practitioners on the detection deficit in oral premalignant and early cancers in Puerto Rico: a qualitative research study.

BACKGROUND: In Puerto Rico, relative to the United States, a disparity exists in detecting oral precancers and early cancers. To identify factors leading to the deficit in early detection, we obtained the perspectives of San Juan healthcare practitioners whose practice could be involved in the detection of such oral lesions. METHODS: Key informant (KI) interviews were conducted with ten clinicians practicing in or around San Juan, Puerto Rico. We then triangulated our KI interview findings with other data sources, including recent literature on oral cancer detection from various geographic areas, current curricula at the University of Puerto Rico Schools of Medicine and Dental Medicine, as well as local health insurance regulations. RESULTS: Key informant-identified factors that likely contribute to the detection deficit include: many practitioners are deficient in knowledge regarding oral cancer and precancer; oral cancer screening examinations are limited regarding which patients receive them and the elements included. In Puerto Rico, specialists generally perform oral biopsies, and patient referral can be delayed by various factors, including government-subsidized health insurance, often referred to as Reforma. Reforma-based issues include often inadequate clinician knowledge regarding Reforma requirements/provisions, diagnostic delays related to Reforma bureaucracy, and among primary physicians, a perceived financial disincentive in referring Reforma patients. CONCLUSIONS: Addressing these issues may be useful in reducing the deficit in detecting oral precancers and early oral cancer in Puerto Rico.

A deficit in biopsying potentially premalignant oral lesions in Puerto Rico.

BACKGROUND: Intraoral lesions clinically suspicious for cancer/precancer should be biopsied and diagnosed histopathologically. We evaluated whether the frequency of oral cancer (OC) cases diagnosed in Puerto Rico (PR) is disproportionately high relative to the frequency of persons with histopathologic diagnoses that would have appeared clinically suspicious for OC/precancer at biopsy. METHODS: All pathology reports for oral (ICD-O-3 C01-C06) soft tissue biopsies generated during 1/2004-5/2005 by seven PR and two New York City (NYC) pathology laboratories were reviewed. The analysis was restricted to persons diagnosed with invasive oral squamous cell carcinoma (OSCC), epithelial dysplasia, or hyperkeratosis/epithelial hyperplasia (HK/EH), i.e., diagnoses associated with lesions clinically suspicious for OC/precancer. The OC relative frequency measured the percentage of persons diagnosed with OSCC among persons with OSCC, dysplasia, or HK/EH. OC relative frequencies for PR and NYC laboratories were compared. RESULTS: Overall, the OC relative frequency was 67% in PR and 40% and 4% in the NYC general and oral pathology laboratories, respectively (each p<0.001). In PR, the OC relative frequency was highest for males (80%). When OC relative frequencies were stratified by pathology laboratory type (general/oral) and compared across PR and NYC, age/gender-specific OC relative frequencies were always higher in PR; however, differences were consistently statistically significant for males only. CONCLUSION: A disparity in the OC relative frequency exists in PR vs. NYC indicating a shortfall in biopsying potentially precancerous oral lesions in PR. PR residents with intraoral lesions suspicious for oral cancer/precancer are most likely to be biopsied only after developing an invasive OC.

Detection of very early oral cancers in Puerto Rico.

We evaluated a possible disparity in the detection of very early oral cancers in Puerto Rico relative to the United States. The percentage of in situ (noninvasive) cases among all oral cancer cases was calculated separately for Puerto Rico and the United States using population-based cancer registry data (1992-2001). In situ cancers constituted 1.2% of oral cancer cases in Puerto Rico and 3.4% in the United States (P<.001). These findings suggest a disparity in very early oral cancer detection in Puerto Rico compared with the United States.

Oral and pharyngeal cancer incidence and mortality among Hispanics, 1996-2002: the need for ethnoregional studies in cancer research.

OBJECTIVES: We investigated whether oral cavity and pharyngeal cancer (OPC) incidence and mortality statistics among Hispanics in New York State differed from those among Hispanics in the United States as a whole. METHODS: OPC incidence and mortality statistics for 1996-2002 were obtained from the New York State Cancer Registry and compared with national statistics released by the Surveillance, Epidemiology, and End Results (SEER) program for the same period. RESULTS: Among Hispanic men, OPC incidence rates were approximately 75% and 89% higher in New York State and New York City, respectively, than national rates reported by the SEER program. No notable differences were identified among Hispanic women. Incidence rates among New York State Hispanic men were 16% higher than those of their non-Hispanic White counterparts. The difference was twice as high (32%) among Hispanic men in New York City. Mortality rates among both men and women exhibited patterns similar to the incidence patterns. CONCLUSIONS: Ethnoregional differences exist in the incidence and mortality rates of OPC in the United States. New York State Hispanic men exhibit much higher incidence and mortality rates than US Hispanics as reported by the SEER program.

Dental caries in twelve- and fifteen-year-olds: results from the basic oral health survey in Haiti.

OBJECTIVE: Reports on oral health investigations in Haiti are sparse. There are only three peer-reviewed published articles on oral health in Haiti. In order to construct a national dataset useful for public health planning, a representative dental caries survey of Haitian school attending children was conducted in 1999. METHODS: This survey was conducted using a modified version of the World Health Organization (WHO) Basic Oral Health Survey (BOHS) pathfinder method. Children ages 12 and 15 years old attending public or private schools in both rural and urban regions were targeted in seven of the nine geographic Departments of Haiti: each Department constituted a strata that was further stratified into the major urban center and one or more rural towns. Four trained examiners, calibrated to WHO caries criteria, conducted the survey RESULTS: Of the total 1,218 examined 12- and 15-year-olds, 31% of the 12-year-olds and 46% of the 15-year-olds had a DMFS of 1 or more, i.e., these percentages are the simple prevalence levels of dental caries for those age groups in Haiti. Mean DMFS scores were 1.01 (SE 0.09) and 2.52 (SE 0.02) for the 12- and 15-year-olds, respectively. No difference was observed between gender, while differences were found by geographical classification. Less than 1% of the children had any dental restorations. CONCLUSIONS: The findings from this investigation suggest that at the population level, permanent dentition caries in early adolescence is a minimal health problem, relative to dental caries in other neighboring Caribbean countries, as well as to other health conditions in Haiti. However, at the individual level, those children afflicted with decay are without dental services for all practical purposes.