Letters

Squamous cell carcinomas of the head and neck

Oral care for patients with cancer needs more than lip service

Precancerous lesions in oral cavity of Indian schoolchildren may hint at epidemic

Oral care for patients with cancer needs more than lip service

EDITORI had hoped to see a mention of the need for oral care for patients with cancer in the review article by Sanderson et al on squamous cell carcinomas of the head and neck, but I was again disappointed.¹ Patients with head and neck cancers must receive a dental assessment and oral care before and after their treatment to ensure minimisation of oral complications for an improved quality of life. The clinical guidelines published by the Royal College of Surgeons of England in 2000 state that a clear pathway of care is necessary to prevent or minimise oral complications.²

However, many patients with cancer still receive no proper dental assessment or preventive treatment to minimise or avert the known and common oral complications of radiation treatment. This may be due, in part, to the lack of resources and recognised local standards of dental care for such patients, as well as to lack of information and apathy.

The Restorative Dentistry Oncology website (www.rdoc.org.uk) was created to increase awareness of the oral complications of cancer treatments and to help patients, dentists, and doctors to find free information on oral cancer easily. The website includes first hand accounts of patients' experiences. A discussion forum offers patients, carers, and interested members of the public the opportunity to ask questions, help others, share ideas and opinions, and learn about other people's experiences in dealing with head and neck cancers. The guides for patients and professionals link to other websites dealing with basic aspects of oral cancer such as treatment and complications. Links cover other concerns that doctors rarely address but that are just as important, such as the financial implications of cancer, financial planning and support, and personal care and support.

A section on tobacco risks includes links on the connection between chewing Gutkha or paan and developing mouth cancer. Although this is mainly a problem on the Indian subcontinent, the United Kingdom has a sizeable immigrant population that continues with these habits. Other sections cover treatment, complications, and spiritual help. A daily dental cartoon helps to bring humour.

I hope that doctors will find the website useful and recommend it to patients and their carers should they ask for information. Oral care for patients with cancer needs more than lip service.

Vinod K Joshi, consultant in restorative dentistry. 
Oral and Facial Specialties, Pinderfields Hospital, Wakefield WF1 4DG v.k.joshi{at}rdoc.org.uk

Precancerous lesions in oral cavity of Indian schoolchildren may hint at epidemic

EDITORSanderson et al's review of squamous cell carcinomas of the head and neck prompts me to describe an unprecedented phenomenon facing India.¹ Consumption of smokeless tobacco, especially Gutkha (a mixture of areca, catechu, betel nut, lime, tobacco, and mint), is rising among school children in rural India.² It is considered to be a harmless mouth freshener, and children therefore consume in large amounts and keep it in the mouth for a long time.²

A survey of school children in a coastal village in the state of Kerala showed a 29% prevalence of tobacco chewing, and another survey in Mizoram showed a rate of 56.5%. The age for initiation for Gutkha in India has been reported as 8-14 years. A survey of 986 school children in a rural part of central India showed leukoplakia in 32, erythroplakia in six, and submucous fibrosis in 18.² Some 50-60% of patients with submucous fibrosis will develop invasive cancers. In 1991, 11 premalignant lesions were found in 200 college students who used tobacco.²

The evidence of early onset of the smokeless tobacco habit and reports of increases in oral precancers among children raise serious concerns of an impending epidemic of oral cancer in this population.³ The age at onset of oral cancer in India is falling and is significantly lower than reported in the rest of the world.³

Smokeless tobacco is becoming popular among children and adolescents in Canada, the United States, Scandinavia, and the United Kingdom. ^{4 5} In the United States the use of smokeless tobacco has increased among adolescent boys and young men in recent years. ^{4 5} National data indicate that 10-12 million Americans use some form of smokeless tobacco.

Tobacco in its various forms has killed more people than al-Qaeda, yet we still lack an international coalition against "tobaccoism." Let the tobacco companies not poison our future generations.

Pankaj Chaturvedi, assistant surgeon, head and neck. 
Tata Memorial Hospital, EB Road, Parel, Mumbai 400 012, India pakajch37{at}yahoo.com

1.	Sanderson RJ, Ironside JAD. Squamous cell carcinomas of the head and neck [with commentary by WI Wei]. BMJ 2002; 325: 822-827[Free Full Text]. (12 October.)
2.	Chaturvedi P, Chaturvedi U. Prevalence of tobacco consumption in school children in rural Indiaan epidemic of tobaccogenic cancers looming ahead in the third world. J Cancer Educ 2002; 17: 6[Medline].
3.	Gupta PC. Mouth cancer in India: a new epidemic? J Indian Med Assoc 1999; 97: 370-373[Medline].
4.	Schaefer SD, Henderson AH, Glover ED, Christen AG. Patterns of use and incidence of smokeless tobacco consumption in school-age children. Arch Otolaryngol 1985; 111: 639-642[Abstract].
5.	Bruerd B. Smokeless tobacco use among native American school children. Public Health Rep 1990; 105: 196-201[ISI][Medline].