Journal of Cancer Therapy, 2013, 4, 1313-1320 Published Online October 2013 ( 1313
Oral Cancer: Health Promotion and Visual Screening
A Study Report*
Augusta P. Silveira1,2#, Augusta Marques3, Miguel Pavão3, Eurico Monteiro1,4, Gabriela Pereira1,
Joaquim Gonçalves1,5, Luís Castro1, Maria Inês Guimarães1,6, Bernardete Carvalho7,
Cláudia Ribeiro8, Teresa Sequeira1,2#
1Faculty of Heath Sciences, Fernando Pessoa University, Porto, Portugal; 2Centre of Health Studies and Research, Coimbra Univer-
sity, Coimbra, Portugal; 3Non-Governmental Organization (NGO): Mundo A Sorrir, Porto, Portugal; 4Portuguese Institute for Onco-
logy, Porto, Portugal; 5Instituto Politécnico do Cávado e do Ave, Barcelos, Portugal; 6Porto, Portugal; 7Well Medical Spa, Porto,
Portugal; 8Health Sciences Department, Portuguese Catholic University, Viseu, Portugal.
Received July 30th, 2013; revised August 28th, 2013; accepted September 5th, 2013
Copyright © 2013 Augusta P. Silveira et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: Oral cancer presents a heterogeneous geographic incidence. Annually, more than 275,000 new cases are
diagnosed worldwide. In spite of the easy accessibility of oral cavity during physical examination, most malignancies
are not diagnosed until late stages of disease. Methods: Oral health promotion was our main objective, risk factors were
identified and oral cavity self-examination was promoted. The population considered (n = 1117) was divided in two
main age groups—a you ngest ( indiv iduals un der 25 year s old) mostly targ eted for or al cancer awar eness an d oral cavity
self examination promotion, and an older group having accumulated potential risk exposure. Results: The results ob-
tained revealed smoking habits and fruits-vegetables consumption deficit as the highest risks factors found. Considering
a Risk Factor Exposure Index analysis, individuals with secondary level of instruction and living in sub-urban areas
assumed the highest risk exposure. Alcohol consumption had also contributed as a significant risk exposure. Conclu-
sions: Some of these risk factors work as biological reward of quality of life deficit. A wide comprehension of the
problem requires a multidisciplinary approach necessarily involving Health and Social Sciences in order to target the
core of oral cancer health promotion. An effective epidemiological strategy must thus support three major aspects:
population knowledge, sensitization and visual screening.
Keywords: Oral Cancer; Visual Screening; Oral Health Promotion; Epidemiological Strategies
1. Introduction
Oral cancer (OC) presents a heterogeneous geographic
incidence and reveals to be more frequent in developing
countries. Annually, more than 275,000 new cases are
diagnosed worldwide—64,000 were identified in Euro-
pean Union (EU) in 2004 1. Five percent of all tumors
occur in head and neck—such cancers are the 6th com-
mon form of cancer in the world and 4th in Europe-appro-
ximately half of them occur in oral cavity con tributing to
an overall of 2.8% of all cancers 2,3.
Oral cavity includes lips, tongue, oral mucosa, gums,
vestibule, mouth floor and palate (ICD9 C00-C06). The
most common localizations are mouth floor, tongue lat-
eral edge and soft palate. The five-year survival rate for
OC is around 50% - 60% 4.
*Competing interests: The author(s) declare that they have no co mpet-
ing interests.
Authors’ contributions: AS, MP and TS conceived of study; MP, AS,
AM, GP, LC, IG and CR participated in the acquisition of data; JG, AS
and TS analysis and interpretation of data; AS and TS drafted, revised
and submitted the manuscript; EM was responsible for the instructions
and guidelines aimed to scientifically prepare and calibrate the teams
involved; JG performed the statistical analysis; BC participated in
manuscript elaboration. All authors read and approved the final manu-
#Corresponding author.
Concerning oral malignancies, squamous cell carci-
noma (SCC) contributes with a significant 90% of such
malignancies. It has been recently reported that overall
incidence and mortality associated with SCC are in-
creasing, with current estimates of gender-standardized
incidence and mortality being 6.6/100,000 and 3.1/
Copyright © 2013 SciRes. JCT
Oral Cancer: Health Promotion and Visual Screening—A Study Report
100,000 in men and 2.9/100,000 and 1.4/100,000 in
women, respectively 5.
As most cases are late diagnosed, therapeutics is either
ineffective or physiologically quite aggressive and ex-
pensive. When surviving is considered, these patients
exhibit a reserved prognosis. Basic physiological func-
tions are often impaired and quality of life of these pa-
tients is severely affected 4,6,7.
The decreasing mortality rates in EU (about 7%) iden-
tified since the beginning of the century are not, unfortu-
nately, a world trend: mortality from OC has been rising
in several o ther regions of the world b eing young peop le
mainly affected 5,8,9.
1.1. Risk Factors
Tobacco and alcohol are the main risk factors associated
with OC development. Tobacco accounts for the highest
share, particularly when non-filter smokers are consid-
ered 8,10. It is estimated that 8 out of 10 patien ts diag-
nosed with OC consume tobacco or have consumed it–
these patients present an increased 5 - 7 fold risk of de-
veloping OC when compared with non-smokers. More-
over, the risk of cancer seems to remain elevated many
years (at least 10) after smoking cessation 11.
Tobacco and alcohol consumption is associated with
approximately 75% of upper aero digestive tract cancers.
Proliferative cells seem to be influenced by alcohol, in-
volving both intracellular (e.g., endocytosis) and inter-
cellular (permeability) pathways 12.
The link of the known risk factors-alcohol and tobacco
with oral microorganisms is recently under investigation.
It seems that infectious agents interfere both in tumor
genesis and defensive factors by causing inflammation
with subsequent release of cytokines and other inflam-
matory mediators, responsible for some oncogenes acti-
vation 13,14.
Periodontal disease has also been shown to increase
the OC statistic 15,16.
Fruits and vegetables consum ption m a y constit ut e a pro-
tective factor against OC. According to the American
Institute for Cancer Research, nutrients such as vitamins
and minerals contained contribute to keeping the body
healthy and strengthening immune system 17. Further-
more, phytochemicals, biologically active compounds found
in fruits and vegetables, can help protect cells from dam-
ages that can lead to cancer. The Mediterranean Diet has
been shown to be associated with reduced OC risk 18-21.
Recent OC molecular biology research has also point-
ed genetic factors as other important risk factors in oral
carcinogenesis predisposition 22.
1.2. Oral Cancer: Visual Screening
Despite the general accessibility of oral cavity during
physical examination, most malignancies concerning this
body part are not diagnosed until late stages of disease.
Despite the fact that no clear advantages in OC screen-
ing were admitted for decades, several studies point to the
obvious advantages associated with visual oral screening
1.3. Oral Cancer: Health Promotion
Although the increased knowledge and progress made on
cancer molecular basis understanding, neither oral cancer
incidence nor the 5-year mortality has not decreased in
the same proportion 25. Such facts suggest that chal-
lenges remain to explore in OC management: prevention,
diagnosis, and surgical and non-surgical treatment. Con-
sidering prevention and diagnosis, comprehensive strate-
gies involving the individual at a community level might
facilitate integration of the knowledge achievement and
population sensitization, needed for decreasing risk fac-
tors exposure 26.
1.4. Aims
The results of an Oral Health Project for OC prevention
are analyzed. Oral health promotion was a main objec-
tive of the Project and oral cavity self-examination was
promoted. Oral visual screening was performed in order
to precociously detect malignant lesions or with malig-
nant transformation potential.
We aimed a further understanding of OC risks factors
identified in order to guide more effective future oral
health measures.
2. Methods
Two main age groups were considered—a youngest
population (under 25 years old) mostly targeted for oral
cancer awareness and oral cavity self-examination pro-
motion, and an older group having an accumulated risk
exposure potential. Socio-demographic, risk exposure
and some life style data were collected in order to further
understan d dete rminants for OC development .
The Otorhinolaringology service from the Portuguese
Institute for Oncology-Porto (IPO-Porto, ORL) perform-
ed training actions for dentists and dentistry students’
finalists. The instructions and guidelines provided aimed
to scientifically prepare and calibrate all 8 dentists’ par-
ticipants and 30 dentistry students’ finalists (Dentistry,
Msc, Fernando Pessoa University, Porto, Portugal) in-
volved in the screening. Eight work teams were com-
posed with at least 1 dentist and 4 dentistry students.
Each screened individual (n = 1117) was invited to
fulfill a questionnaire concerning:
1) Socio-demographic data (gender, age, residency and
2) Ri sk factors exposure (tobacco habits, eth yli c ha bit s;
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Oral Cancer: Health Promotion and Visual Screening—A Study Report 1315
solar radiation; risky profession or risk agents familiarity,
fruit and vegetables consumption deficit, family history
for OC);
3) Dental health status (oral hygiene; dental prosthesis;
parafunctional habits and DMF index-decay/missing/
filled). Concerning oral hygiene, daily brushing times
and oral hygiene devices were used to classify as “ade-
quate hygiene level” and “poor hygiene level”. It was
considered an adequate oral hygiene if: a) brushing was
twice a day and took place in the morning after breakfast
and at night before sleeping time and b) hygiene devices
used were at least brush, toothbrush and dental floss.
Previous oral infection (Herpes Virus, Human Papi-
loma Virus or Candida) was not considered for OC risk
rating because there was no access to clinical records.
Work teams accomplished 1117 oral visual screenings
and held 40 informative sessions concerning OC aware-
ness. About 30 - 40 individuals attended each session
that lasted for about 20 minutes. A debate moment fol-
lowed each session and all questions placed were an-
All participants resided in Oporto district and volun-
tarily gave their written informed consent.
This visual oral screening study counted on media di-
vulgation (television, radio, journals and internet). Fur-
ther, 10,000 informative flyers concerning OC preven-
tion and visual screening, were distributed.
A Risk Factor Exposure Index (RFEI) was designed to
express the balance between risk factor exposure and
protection. RFEI was calculated based on the number of
cigarettes smoked per day, adding 1 point for every 5
cigarettes, the number of years of smoking by adding one
point for every 5 years, also adding a point (per item) for
drinking alcohol, living with smokers, having parafunc-
tional habits, and excessive sun exposure. The value ob-
tained was subtracted 1 point for each daily meal involv-
ing fruit consumption. The measurement was expressed
as a percentage.
Student t test for independent samples was used to in-
vestigate risk factors differences when analyzed accord-
ing to gender, alcohol consumption, and suspected be-
nign lesion. In order to evaluate the differences for risk
factor among age groups, years of schooling and residen-
tial area, an analysis of variance was performed. The
identification of differences between each class of each
group was performed by Bonferroni test.
The Statistical Package Social Sciences (SPSS) ver-
sion 17 for windows, analyzed the collected data.
3. Results
All participants (n = 1117) fulfilled the questionnaire and
the vast majority of questions (only 67 and 2 missing
questions were detected concerning being ex-smokers
and having maladjusted dental prosthesis, respectively).
3.1. Socio-Demographic Characterization
Major socio-demographic characteristics are depicted in
Table 1.
The studied population included both genders in simi-
lar numbers (not significant differences) being the major-
ity young (less than 24 years old). A low academic level
was a constant: when considering old enough to conclude
any education level, it was found that only 27.8% (140/
508) concluded the secondary level and a few 4.6% (15/
315) concluded University. Individuals were either from
urban, sub-urban or rural locations.
3.2. Risk Exposure
Major reported risk exposures are depicted in Table 2.
Most individuals declare to be non-smokers (n = 900)
and among these 7.8% (n = 70) admitted to be ex-smok-
ers. Smoking, revealed thus to be one of the most fre-
quent risk behaviors among all others considered. Figure
1 characterizes the smoking population considering age
and gender.
It was found that youngest group, male individuals
(less than 14 years old) smoke significantly more than
females. This is indeed the general tendency exception
made and inverted when individuals are 25 - 34 years old.
Table 1. Socio-demographic data of the studied population
(n = 1117).
male 510 (45.7)
female 601 (54.3)
I Less than 14 614 (55.0)
II 15 - 24 188 (16.8)
III 25 - 34 66 (5.9)
IV 35 - 44 79 (7.1)
V 45 - 54 64 (5.7)
VI 55 - 64 32 (2.9)
VII More than 65 74 (6.6)
Schooling (years)
Basic (1 - 9) 962 (86.1)
Secondary (10 - 12) 140 (12.5)
University (+13) 15 (1.3)
Residential area
Urban 427 (38.2)
Sub-urban 262 (23.5)
Rural 428 (38.3)
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Oral Cancer: Health Promotion and Visual Screening—A Study Report
Table 2. Oral cancer risk exposure distr ibution found in the
studied population (n = 1117).
Smokers 217 900
Ex-smokers 70 980
Severe ethylic habits 78 1039
Solar radiation 239 878
Parafunctional habits 407 710
Maladjusted dental prosthesis 94 1021
Poor oral hygiene 510 607
Risky profession or risk
agents familiarity 85 1032
Fruit and vegetables
consumption deficit 1083 34
Family his to ry for oral cancer 192 995
Figure 1. Smokers percentage distribution considering gen-
der and age.
Tobacco consumption revealed to be highest in the 35 -
54 years old range—later then a decrease is observed,
particularly significant in females.
The following figure illustrates daily tob acco exposure
It was observed that tobacco exposure presented two
main peaks: 6 - 10 years (n = 36, 25 females and 11
males) and 21 - 30 years (n = 34, 11 females and 23
males). For each period range, exposure is mainly mas-
culine, is similar for periods comprising 3 - 5 years and
16 - 20 years and is mainly feminine both in 6 - 10 and
11 - 15 years of exposure. The period of tobacco expo-
sure that included more females was 6 - 10 years (n =
About thirty eight percent (n = 306) of all participants
admitted to perform regularly oral self-examination.
The associated Risk Factor Exposure Index (RFEI)
found in the studied population is presented in Ta b l e 3.
No significant differences were found among genders
but when age was considered, several differences were
noticed: first, RFEI increases linearly until its peak at ag e
group 45 - 54 years old and than declines at similar levels
to those found in the youngest population; second: the
age groups 15 - 24 years and 55 - 64 years old assume
similar risks being lower than the 25 - 54 years old indi-
viduals; third: 35 - 54 years old individuals assume the
Table 3. Risk Factor Exposure Index (RFEI) found in the
studied population for the socio-demographic variables
(gender, age, schooling years and residency), detected sus-
pected lesions or benign pathology (n = 1117).
Characteristics RFEI (%)
male 24.6
female 19.4
I Less than 14 15.1
II 15 - 24 23.4
III 25 - 34 33.4
IV 35 - 44 34.7
V 45 - 54 39.4
VI 55 - 64 28.7
VII More than 65 15.2
Schooling (years)
Basic (1 - 9) 21.2
Secondary (10 - 12) 25.3
University (+13) 22.8
Residential area
Urban 21.3
Sub-urban 24.5
Rural 16.7
Alcohol consumption
Yes 39.5
No 20.3
Suspected lesion
Yes 24.8
No 21.8
Benign pathology
Yes 24.8
No 21.8
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Oral Cancer: Health Promotion and Visual Screening—A Study Report 1317
highest risk exposure.
Considering formal education it was found that indi-
vidual with secondary level assumed the highest risk
exposure, significantly different from other education
levels (p = 0).
It was found that rural individuals presented the lower
RFEI that revealed to be significantly different from ur-
ban (p = 0) and sub-urban (p = 0). The highest RFEI wa s
found in sub-urban individuals and was significantly dif-
ferent from urban (p = 0.01).
Alcohol consumption (n = 78) contributed as a sig-
nificant higher risk exposure (p = 0). Identification of a
benign pathology or a suspected lesion, although pre-
sented a higher RFEI, differences were not significant—
the low number of positiv e individuals (n = 33 and n=15,
respectively) most probably contributed to this circum-
During oral visual screening 48 individuals were re-
ferred for clinical observation because they presented
some oral pathology. Twenty-four lesions with malign
transformation potential or suspected malignancy were
detected (2% from all screened individuals). After further
clinical observation all targeted suspicions were then
negatively confirmed.
4. Discussion
We found that an important risk factor such as smoking
is already present at young ages (less than 14 years old).
Tobacco consumption revealed to be highest in the 15 -
24 years old range and later after a decrease as a whole is
observed (Figure 1). This seems to agree with d ata found
in Portugal by Borges and collaborators 27. Although
the across-the-board agreement with anti-smoking mea-
sures, along with hope for a reduced general and indi-
vidual consumption described no changes were detected
in the population studied 28.
Alcohol consumption together with tobacco use has
been recognized as an important synergistic risk factor
for OC for almost 50 years 29,30. The heterogeneous
population studied might explain the low percentage of
severe ethylic habits found. However, when considering
only the older group, the percentage of individuals with
severe ethylic habits increased significantly.
The low educational level observed and a significant
proportion of individual’s exposed to tobacco for quite
long periods (Figure 2), supports the need of preventive
strategies of oral health promotion, particularly focused
among the youngest. Knowledge and attitudes about
smoking have been described as varying with socio-
demographic characteristics such age, education level
and residential area 31-34.
The World Health Organization recommends a con-
sumption of at least 400 g per day-five servings per day
of fruits and vegetables 38, being known that dietary
Figure 2. Tobacco exposure (years) considering gender.
deficiencies, especially vitamins A/C/E and iron are con-
sidered risk factors 35-37. Moreover, Petersen (2009)
showed that heavy intake of alcoholic beverages is asso-
ciated with nutrient deficiency, which appears to contrib-
ute independently to oral carcinogenesis 38. Fruits and
vegetables consumption deficit reveled to be the highest
risk factor in the studied population. This represents a
concerning question taking in account the high percent-
age of young individual an d the cumulative effect risk.
Despite the general accessibility of the oral cavity dur-
ring physical examination, many malignancies are not
diagnosed until late stages of disease 39. Systematic
literature reviews of effectiveness in screening for OC
and pre cancer made until early 2000 were found to pro-
vide insufficient available data to make an unequivocal
determination as to the effectiveness of OC screening
programmers at the time 40. Although OC is almost
always preceded by visible changes in the oral mucosa
most situations are currently detected at a late stage,
when treatment is complex, costly, and has poor out-
comes 41.
Sankaranarayanan and collaborators (2005) performed
a landmark study when studied a high-risk population in
India (n = 96.517). They proved for the first time that
oral visual inspectio n was effective in reducing OC mor-
tality. According to their data, visual oral screening was
ascribed to a potential of preventing at least 37,000 OC
deaths worldwide 23. More recently, I. How et al.
(2011) reported a high sensitivity and specificity (98.9%
and 98.7%, respectively) in an oral cavity visual screen-
ing for cancer conducted in a large male population
(more then 13,000 men) from a tertiary medical center
The association of the well-known risk factors for oral
cancer and its easy detect ability—it is almost always
preceded by visible changes in the oral mucosa-con-
verted this disease into a potentially preventable one 25,
However, the diagnostic delay is still a reality—it
seems to be assigned by the lack of awareness of the
signs, symptoms, and risk factors for OC, as well as a
disappointing absence of prevention and early detection
Copyright © 2013 SciRes. JCT
Oral Cancer: Health Promotion and Visual Screening—A Study Report
by health-care providers 41. Indeed, a recent survey
regarding dentists’ knowledge of risk factors and diag-
nostic concepts of OC, Decuseara et al. (2011) found that
they appear to be generally knowledgeable regarding
diagnostic concepts and risk factors 43. Nevertheless,
these dentists reported a significan t lack of patient edu ca-
tion regarding prevention and early detection of OC. The
fact that economical disadvantaged populations do not
visit a dentist regularly further increases its burden risk.
The low educational level found also may account for
social needs resulting as a source of non-healthy life-
styles. It is known that both tobacco and alcohol con-
sumption constitute ancient adaptive strategies to over-
come unfavorable conditions-such as hunger and cold-
activating the dopam i nergic r ewar d system 44.
This fact concur to explain why many Public Health
measures aimed at preventing OC fail their final goal
whenever the erad ication of such non-h ealthy lifestyles is
not considered 42.
Our results corroborate others 35 suggesting that it
might be possible to impro ve OC mortality by modifying
country-based determinants lifestyles related (not only
smoking and drinking prevalence) and improving mul-
tidisciplinary approaches prepared by both Social and
Health Sciences—it is fundamental a better knowledge
for an efficient action.
5. Conclusions
The results obtained revealed that smoking habits and
fruits-vegetables consumption deficit contributed as the
highest risks factors in the studied population. From
RFEI analysis, individuals with secondary level and
those with sub-urban residential area assumed the highest
risk exposure. Alcohol consumption also contributed as a
significant higher risk exposure.
Future oral health measures for th is group must take in
account-tobacco cessation sessions and nutritional re-
education, especially for younger individuals, once these
risk factors have a cumulative effect.
Some of these risk factors work as biological reward
of quality of life deficit. A wide comprehension of the
problem requires a multidisciplinary approach necessar-
ily involving Health and Social Sciences in order to tar-
get the core of OC health promotion.
An effective epidemiological strategy must thus sup-
port three major aspects: population knowledge, popula-
tion sensitization and visual screening.
6. Acknowledgements
We acknowledge all people who have voluntarily col-
laborated in the study, all health professionals from the
Portuguese Institute of Oncology, Porto, Portugal (IPO-
Porto) involved and the ORL Service for their generous
support. We also acknowledge the Centre of Health
Studies and Research of the University of Coimbra and
the Portuguese High Commissioner for Health.
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