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Diet and Oral Cancer
A Peer-Reviewed Publication
Written by Jeff Burgess, DDS, MSD
Abstract
The 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 Profile
Jeff 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 [email protected] .
Author Disclosure
Jeff Burgess, DDS, MSD, has no potential conflicts of interest to
disclose.
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Publication date: July 2014
Expiration date: June 2017
Supplement to PennWell Publications
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(10/31/2015) Provider ID# 320452.
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 [email protected]
Educational 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.
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.
Abstract
The relationship between diet and oral cancer is complex and not
fully understood at present. A number of foods and food products
havebeenassociatedwiththedevelopmentoforalcancerandsome
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.
Oral cancer is widespread throughout the world with estimates 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 carcinomas 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 subjects matched for age and gender and dietary information were
assessed for ‘food frequency’. After adjustment for a number
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of variables, including tobacco smoking and alcohol consumption, 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 (versus 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 supplementation 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 metabolized. 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 -Selenium 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]-carotene, [alpha]-carotene, cryptoxanthine, lutein, and lycopene),
particularly [beta]-carotene).11 It is hypothesized that these substances 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 salivary 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
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 nutritional 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:
Areca nuts, betel nuts, paan, gutka
Animal fat
Canton-style salted fish
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
1.
2.
3.
4.
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-cancerclinical/pdf/CD005195.pdf. Assessed 4/22/14.
11. h t t p : / / f i n d a r t i c l e s. c o 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):27681.
13. Ljju VB, Jeena K, Kuttan R. An evaluation of antioxidant, antiinflammatory, 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/cancer topics/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 metaanalysis 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.
Bibliography
Author profile
1. 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
Jeff 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 [email protected] .
RDH | July 2014
Author Disclosure
Jeff Burgess, DDS, MSD, has no potential conflicts of interest
to disclose.
rdhmag.com | 61
Online Completion
Use 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.
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returning to the site, sign in and return to your Archives Page.
Questions
1. It is estimated that the total number of oral
cancer cases worldwide is:
a.100,000
b.200,000
c.400,000
d.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 nuts
b.Paan
c. Areca nuts
d. All of the above
4. Which of the following dietary products
has been associated with a reduced risk of
nasopharyngeal cancer?
a.
b.
c.
d.
Fresh fruit
Canton-style herbal tea
Herbal slow-cooked soup
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.Fried
b.Raw
c. Cooked over steam
d.Boiled
6. Which of the following statements is inaccurate, 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 micronutrients 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]-tocopherol
b.Selenium
c. Carotenoids [beta]-carotene
d.Flavonoids
8. In an interesting study looking at antioxidant 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 b
d. Neither a or b
9. Which of the following food products
contain beta carotene?
a.Carrots
b.Mangos
c.Squash
d. All of the above
10. Which of the following beverages has not
been associated with a reduced risk of oral
cancer?
a. Green tea
b.Coffee
c. Canton-style herbal tea
d.Alcohol
Notes
62 | rdhmag.com
RDH | July 2014
ANSWER SHEET
Diet and Oral Cancer
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Educational Objectives
If not taking online, mail completed answer sheet to
Academy of Dental Therapeutics and Stomatology,
1. Describe the foods that increase or decrease oral cancer risk.
A Division of PennWell Corp.
2. Identify the supplements that may reduce oral cancer risk.
P.O. Box 116, Chesterland, OH 44026
or fax to: (440) 845-3447
3. Identifythesupplementsuggestedforcancerprotectionthatdoesnothavestrongscientificsupport.
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